Clinical Review
Skin diseases associated with Malassezia species

https://doi.org/10.1016/j.jaad.2003.12.034Get rights and content

Abstract

The yeasts of the genus Malassezia have been associated with a number of diseases affecting the human skin, such as pityriasis versicolor, Malassezia (Pityrosporum) folliculitis, seborrheic dermatitis and dandruff, atopic dermatitis, psoriasis, and—less commonly—with other dermatologic disorders such as confluent and reticulated papillomatosis, onychomycosis, and transient acantholytic dermatosis. Although Malassezia yeasts are a part of the normal microflora, under certain conditions they can cause superficial skin infection. The study of the clinical role of Malassezia species has been surrounded by controversy because of their fastidious nature in vitro, and relative difficulty in isolation, cultivation, and identification. Many studies have been published in the past few years after the taxonomic revision carried out in 1996 in which 7 species were recognized. Two new species have been recently described, one of which has been isolated from patients with atopic dermatitis. This review focuses on the clinical, mycologic, and immunologic aspects of the various skin diseases associated with Malassezia. It also highlights the importance of individual Malassezia species in the different dermatologic disorders related to these yeasts.

Section snippets

SD/D

SD/D is perhaps the most common disease associated with Malassezia yeasts, occurring in 1% to 3% of the general population.19., 20. The incidence of SD/D is much higher in patients who are immunocompromised, especially those with AIDS, ranging from 30% to 33%.21., 22. Dandruff has recently received much attention, as its presence can lead to loss of self-esteem and a negative social image.20 It is a disorder that is generally discussed alongside SD because of the scaling effect of the scalp.

Pityriasis versicolor

Pityriasis versicolor is a chronic superficial fungal disease that is characterized by the appearance of round to oval lesions, most commonly found on the trunk and upper aspects of the arms. These lesions vary in color, and can be hypopigmented (white) or hyperpigmented (pink, tan, brown, or black). Flaking is evident, although in larger lesions this may occur only at the border. Lesions may be round or oval, becoming confluent in advanced cases of the disorder. Generally, pityriasis

Malassezia (pityrosporum) folliculitis

Like pityriasis versicolor, Malassezia folliculitis is associated with a clear pattern of Malassezia colonization. Although the transformation of the yeast cells to their hyphal form is unique to pityriasis versicolor, histologic examination of patients with Malassezia folliculitis shows, as the name suggests, invasion of the hair follicles with large numbers of Malassezia yeasts.80 This invasion results in the development of erythematous papules, and sometimes pustules, which may be either

AD

AD is a chronic inflammatory disorder marked by pruritus (often intense) and characteristic eczematous lesions with erythema, fine scaling, and thickening of the epidermis. Genetic factors are known to play an important role in the development of this disorder and many patients have a family history of AD, allergic rhinitis, asthma, or a combination of these. If both parents are carriers of the disease, the risk for children is as high as 70%.97 In many patients, AD is present from childhood

Psoriasis

The role of Malassezia species in psoriasis is still undetermined, but several reports have associated these lipophilic yeasts with the development of skin lesions in psoriasis. Psoriasis is characterized by hyperproliferation and hyperkeratinization of the epidermis. The cases most commonly associated with the yeasts are those that tend to involve the scalp.140 Again, this hypothesis is supported by the response of scalp psoriasis to ketoconazole,141 and also by analysis of the association

Other dermatolgic disorders

There have been a few scattered case reports in the literature associating Malassezia yeasts with various other skin conditions. In particular, Malassezia has been shown to be involved in at least some cases of confluent and reticulated papillomatosis.149., 150., 151. In one case, the patient was successfully treated using selenium sulfide, a traditional topical treatment for pityriasis versicolor. A possible link between Malassezia and transient acantholytic dermatosis has also been suggested,

Treatment

Most of the literature addressing the treatment of the conditions discussed in this article is concerned with those diseases most closely linked to Malassezia yeasts: pityriasis versicolor; SD/D; and Malassezia folliculitis. In the case of the other conditions, there are isolated reports of the efficacy of selenium sulfide (for confluent and reticulated papillomatosis and for transient acantholytic dermatosis) or ketoconazole (for AD and scalp psoriasis), as described above.

Malassezia yeasts

Conclusions

Our knowledge about the pathogenesis of Malassezia-related diseases has increased tremendously during the last decade. Although 7 of the 8 lipophilic Malassezia species can be isolated, with varying frequency, from human skin, it appears that the pathologic response is species-specific. The ninth species, M pachydermatis, does not need a source of lipid to sustain growth, is able to grow on routine laboratory media, and is rarely implicated in disease of human beings who are immunocompetent.

References (183)

  • G. Gaitanis et al.

    Identification of Malassezia species from patient skin scales by PCR-RFLP

    Clin Microbiol Infect

    (2002)
  • D.H. Stein

    Superficial fungal infections

    Pediatr Clin North Am

    (1983)
  • D. Borelli et al.

    Tinea versicolor: epidemiologic, clinical, and therapeutic aspects

    J Am Acad Dermatol

    (1991)
  • O. Back et al.

    Pityrosporum folliculitis: a common disease of the young and middle-aged

    J Am Acad Dermatol

    (1985)
  • S. Jacinto-Jamora et al.

    Pityrosporum folliculitis in the Philippines: diagnosis, prevalence, and management

    J Am Acad Dermatol

    (1991)
  • J. Faergemann et al.

    An immunologic and cultural study of Pityrosporum folliculitis

    J Am Acad Dermatol

    (1986)
  • B. Sina et al.

    Intrafollicular mucin deposits in Pityrosporum folliculitis

    J Am Acad Dermatol

    (1995)
  • S. Rhie et al.

    Clinical features and treatment of Malassezia folliculitis with fluconazole in orthotopic heart transplant recipients

    J Heart Lung Transplant

    (2000)
  • K. Thestrup-Pedersen

    The incidence and pathophysiology of atopic dermatitis

    J Eur Acad Dermatol Venereol

    (1996)
  • D. Borelli

    [Pityriasis versicolor due to Malassezia ovalis]

    Mycopathologia

    (1985)
  • E. Guého et al.

    The genus Malassezia with description of four new species

    Antonie Van Leeuwenhoek

    (1996)
  • T. Sugita et al.

    New yeast species, Malassezia dermatis, isolated from patients with atopic dermatitis

    J Clin Microbiol

    (2002)
  • A. Nell et al.

    Identification and distribution of a novel Malassezia species yeast on normal equine skin

    Vet Rec

    (2002)
  • A.K. Gupta et al.

    Quantitative culture of Malassezia species from different body sites of individuals with or without dermatoses

    Med Mycol

    (2001)
  • A. Nakabayashi et al.

    Identification of Malassezia species isolated from patients with seborrhoeic dermatitis, atopic dermatitis, pityriasis versicolor and normal subjects

    Med Mycol

    (2000)
  • A.K. Gupta et al.

    Epidemiology of Malassezia yeasts associated with pityriasis versicolor in Ontario, Canada

    Med Mycol

    (2001)
  • C.M. Gemmer et al.

    Fast, noninvasive method for molecular detection and differentiation of Malassezia yeast species on human skin and application of the method to dandruff microbiology

    J Clin Microbiol

    (2002)
  • A.K. Gupta et al.

    Molecular differentiation of seven Malassezia species

    J Clin Microbiol

    (2000)
  • T. Boekhout et al.

    Molecular typing of Malassezia species with PFGE and RAPD

    Med Mycol

    (1998)
  • H.J. Chang et al.

    An epidemic of Malassezia pachydermatis in an intensive care nursery associated with colonization of health care workers' pet dogs

    N Engl J Med

    (1998)
  • P.A. Mickelsen et al.

    Clinical and microbiological features of infection with Malassezia pachydermatis in high-risk infants

    J Infect Dis

    (1988)
  • A. Van Belkum et al.

    Monitoring spread of Malassezia infections in a neonatal intensive care unit by PCR-mediated genetic typing

    J Clin Microbiol

    (1994)
  • R. Brooks et al.

    Systemic infection with Malassezia furfur in an adult receiving long-term hyperalimentation therapy

    J Infect Dis

    (1987)
  • I. Surmont et al.

    Malassezia furfur fungaemia in infants receiving intravenous lipid emulsions. A rarity or just underestimated?

    Eur J Pediatr

    (1989)
  • S.J. Weiss et al.

    Malassezia furfur fungemia associated with central venous catheter lipid emulsion infusion

    Heart Lung

    (1991)
  • H.R. Ashbee et al.

    Immunology of diseases associated with Malassezia species

    Clin Microbiol Rev

    (2002)
  • C.F. Farthing et al.

    Skin disease in homosexual patients with Acquired Immune Deficiency Syndrome (AIDS) and lesser forms of human T cell Leukaemia Virus (HTLV III) disease

    Clin Exp Dermatol

    (1985)
  • A.C. Bulmer et al.

    The antifungal action of dandruff shampoos

    Mycopathologia

    (1999)
  • J. McGrath et al.

    The control of seborrhoeic dermatitis and dandruff by antipityrosporal drugs

    Drugs

    (1991)
  • C. Pierard-Franchimont et al.

    From axioms to new insights into dandruff

    Dermatology

    (2000)
  • G.C. Priestley et al.

    The microbiology of dandruff

    Br J Dermatol

    (1976)
  • J. Faergemann

    Seborrheic dermatits (dandruff)

    (2000)
  • S. Shuster

    The aetiology of dandruff and the mode of action of therapeutic agents

    Br J Dermatol

    (1984)
  • G.E. Piérard et al.

    Prolonged effects of antidandruff shampoos–time to recurrence of Malassezia ovalis colonization of skin

    Int J Cosm Sci

    (1997)
  • C.L. Wilson et al.

    Incidence of seborrhoeic dermatitis in spinal injury patients

    Br J Dermatol

    (1988)
  • J.A. Cotterill et al.

    Age and sex variation in skin surface lipid composition and sebum excretion rate

    Br J Dermatol

    (1972)
  • P. Mayser et al.

    Decreased susceptibility of Malassezia furfur to UV light by synthesis of tryptophane derivatives

    Antonie Van Leeuwenhoek

    (1998)
  • P. Mayser et al.

    Pityriacitrin–an ultraviolet-absorbing indole alkaloid from the yeast Malassezia furfur

    Arch Dermatol Res

    (2002)
  • J.L. Burton et al.

    Seborrhoea is not a feature of seborrhoeic dermatitis

    Br Med J

    (1983)
  • R. Sabouraud

    Maladies du cuir cheveluII. Les maladies desquamatives

    (1904)
  • Cited by (426)

    • Tinea Versicolor in an Infant

      2024, Journal of Pediatrics
    • Cutaneous Fungal Infections in Older Adults

      2024, Clinics in Geriatric Medicine
    • Ethnic differences in hair

      2023, Procedures in Cosmetic Dermatology: Hair Restoration
    • Hair cosmetics, styling, and processing

      2023, Procedures in Cosmetic Dermatology: Hair Restoration
    View all citing articles on Scopus

    Supported in part by a grant from Proctor and Gamble.

    Disclosure: Supported in part by a grant from Proctor and Gamble.

    View full text