Folliculitis Decalvans Has a Heterogeneous Microbiological Signature and Impaired Immunological Response.

BACKGROUND: Folliculitis decalvans (FD) is a rare primary neutrophilic scarring alopecia whose etiology has not been completely elucidated yet. OBJECTIVE: The aim of the study was to determine if the follicular microbiota residing in FD-affected hair follicles had a distinct microbiological signature and if an aberrant immune response was present in the pathogenesis of FD. METHODS: We conducted a cross-sectional study of 10 patients affected by FD. Trichoscopy-guided follicular biopsies were taken from affected and healthy scalp to identify the follicular microbiome using next-generation sequencing. We searched for microbiological biomarkers of FD-affected follicles using the linear discriminant analysis (LDA) effect size (LEfSe) tool. Additionally, peripheral blood mononuclear cells were obtained, and their cytokine production was quantified after incubation with pathogen-associated molecular patterns isolated from patients' biopsies and compared with healthy controls. RESULTS: ß-diversity analysis showed statistically significant differences regarding bacteria comparing follicular microbiota of healthy and FD-affected hairs. Ruminococcaceae, Agathobacter sp., Tyzzerella sp., and Bacteriodales vadin HA21 family were good predictors of disease status. IL-10, TNF-α, and IL-6 levels were significantly decreased in patients after incubation with various strains of bacteria compared with controls. CONCLUSION: FD hair follicles have a specific heterogenous follicular bacterial microbiota signature. Additionally, these patients seem to have an impaired immunological response.

Clinico-laboratory findings of Malassezia folliculitis in Indonesia: A multicentre study.

BACKGROUND: Malassezia folliculitis (MF) is a humid-favoured fungal skin disease caused by Malassezia species. Inaccurate treatments, changes in skin flora and disease exacerbation are often occurred due to oversights in the diagnosis. Several diagnostic methods are established for MF. OBJECTIVE: To identify clinico-laboratory findings of Malassezia folliculitis in Indonesia. METHODS: The study was conducted from January 2014 to December 2018 in seven referral teaching hospitals. Medical records of MF-diagnosed patients were obtained and analysed using the binomial test, chi-square test and Cohen's Kappa coefficient in SPSS 26.0. RESULTS: A total of 353 cases of MF were identified in seven referral teaching hospitals in Indonesia, 66.3% of which were males and 33.7% were females, dominated by the 17-25 years old group (44.5%). Itchy sensation (83.9%) was a major subjective complaint. Lesions were majorly found on the trunk-chest, back and shoulder (68.3%), while the clinical manifestation are mostly follicular papule-pustular lesions (62.1%). Patients were 87.4% positive by KOH examination (modified Jacinto Jamora's criteria) and 69.1% positive by Wood's lamp. Generally, sex, age, subjective complaint, lesion location, clinical manifestation and both examinations were statistically significant (p < .001). A significant relationship between all the clinical criteria of the patients in the KOH especially the clinical manifestation was significantly related to Wood's lamp. The Cohen's Kappa assessment suggested that there was an agreement between KOH and Wood's lamp (κ = -0.272, p < .001). CONCLUSION: The clinical symptoms of Malassezia folliculitis are dominated by pruritus, papulopustular follicular lesions on the trunk and the presence of spore load.

Common condition with uncommon cause: fungal folliculitis in immunosuppressed patient with Blau syndrome.

We present a case of a patient with a history of Blau syndrome, who presented with acute onset of widespread florid painful folliculitis rash, which was resistant to the treatment with multiple courses of antibiotics in the community. Despite of the negative skin swab and negative periodic acid-schiff (PAS)stain on the skin biopsy, clinical diagnosis was fungal folliculitis and patient responded well to the course of itraconazole.

Hostage to history - questioning the duration of systemic antimicrobial therapy for the treatment of canine superficial bacterial folliculitis.

Current guidelines for the use of systemic antimicrobials for the treatment of superficial bacterial folliculitis in dogs include the recommendation that the disease be treated for a minimum of 3 weeks and for at least 1 week beyond clinical resolution. With increasing antimicrobial resistance being noted for bacteria involved in this condition, as well as the increased use of evidence-based medicine, this dogma needs to be reevaluated.

Dermoscopy as an Auxiliary Tool in the Assessment of Malassezia Folliculitis: An Observational Study / Dermatoscopia como herramienta auxiliar en la evaluación de foliculitis por Malassezia: estudio observacional

Malassezia folliculitis is an under-recognizedentity commonly affecting the face and upper trunk. Clinical picture mimics acne vulgaris and diagnosis is challenging at times. 10% potassium hydroxide examination is usually performed to confirm the diagnosis. This study sought to describe the dermoscopic features in Malassezia folliculitis. Patients diagnosed clinically with Malassezia folliculitis and confirmed by 10% potassium hydroxide preparation were included in the study. Dermoscopy was performed with a videodermatoscope [Dinolite AM413ZT; Polarising] from the most representative lesion. A total of 45 patients (M:F = 1:0.8 ) were recruited. All patients had monomorphic papulo-pustular lesions. Itching was present in 64.4% patients. Dermoscopy reveled folliculocentricity (100%), perilesional background erythema (100%), dotted/linear/tortous vessels (88.9%), dirty white scaling (77.8%), hypo pigmentation of hair follicle (64.4%), coiled/looped hairs (57.8%) and broken hairs (13.3%). In conclusion, dermoscopy shows typical features in Malassezia folliculitis and can serve as a office based tool for identification of this entity (AU)

La foliculitis por Malassezia es una entidad que no está debidamente reconocida y que afecta normalmente a la cara y tronco superior. El cuadro clínico remeda el acné vulgar, siendo a veces difícil su diagnóstico. Normalmente se realiza un examen con hidróxido de potasio al 10% para confirmar el mismo. El objetivo de este estudio fue describir las características dermatoscópicas de la foliculitis por Malassezia, incluyéndose en el mismo a los pacientes diagnosticados clínicamente y confirmados mediante aplicación de hidróxido de potasio al 10%. La dermatoscopia fue realizada con un videodermatoscopio [Dinolite AM413ZT; Polarising] en la lesión más representativa. Se incluyó a un total de 45 pacientes (V:M = 1:0.8). Todos los pacientes tenían lesiones monomórficas papulopustulosas. El 64% de los pacientes presentó prurito. La dermatoscopia reveló foliculocentricidad (100%), eritema circundante perilesional (100%), vasos punteados/lineales/tortuosos (88,9%), escamas de color gris parduzco (77,8%), hipopigmentación del folículo piloso (64,4%), pelos en espiral/enrollados (57,8%) y rotura del pelo (13,3%). En conclusión, la dermatoscopia muestra las características típicas de la foliculitis por Malassezia, pudiendo servir de ayuda en consulta como herramienta para la identificación de esta entidad (AU)

[Artículo traducido] Dermatoscopia como herramienta auxiliar en la evaluación de foliculitis por Malassezia: estudio observacional / Dermoscopy as an Auxiliary Tool in the Assessment of Malassezia Folliculitis: An Observational Study

La foliculitis por Malassezia es una entidad que no está debidamente reconocida y que afecta normalmente a la cara y tronco superior. El cuadro clínico remeda el acné vulgar, siendo a veces difícil su diagnóstico. Normalmente se realiza un examen con hidróxido de potasio al 10% para confirmar el mismo. El objetivo de este estudio fue describir las características dermatoscópicas de la foliculitis por Malassezia, incluyéndose en el mismo a los pacientes diagnosticados clínicamente y confirmados mediante aplicación de hidróxido de potasio al 10%. La dermatoscopia fue realizada con un videodermatoscopio [Dinolite AM413ZT; Polarising] en la lesión más representativa. Se incluyó a un total de 45 pacientes (V:M = 1:0.8). Todos los pacientes tenían lesiones monomórficas papulopustulosas. El 64% de los pacientes presentó prurito. La dermatoscopia reveló foliculocentricidad (100%), eritema circundante perilesional (100%), vasos punteados/lineales/tortuosos (88,9%), escamas de color gris parduzco (77,8%), hipopigmentación del folículo piloso (64,4%), pelos en espiral/enrollados (57,8%) y rotura del pelo (13,3%). En conclusión, la dermatoscopia muestra las características típicas de la foliculitis por Malassezia, pudiendo servir de ayuda en consulta como herramienta para la identificación de esta entidad (AU)

Malassezia folliculitis is an under-recognizedentity commonly affecting the face and upper trunk. Clinical picture mimics acne vulgaris and diagnosis is challenging at times. 10% potassium hydroxide examination is usually performed to confirm the diagnosis. This study sought to describe the dermoscopic features in Malassezia folliculitis. Patients diagnosed clinically with Malassezia folliculitis and confirmed by 10% potassium hydroxide preparation were included in the study. Dermoscopy was performed with a videodermatoscope [Dinolite AM413ZT; Polarising] from the most representative lesion. A total of 45 patients (M:F = 1:0.8 ) were recruited. All patients had monomorphic papulo-pustular lesions. Itching was present in 64.4% patients. Dermoscopy reveled folliculocentricity (100%), perilesional background erythema (100%), dotted/linear/tortous vessels (88.9%), dirty white scaling (77.8%), hypo pigmentation of hair follicle (64.4%), coiled/looped hairs (57.8%) and broken hairs (13.3%). In conclusion, dermoscopy shows typical features in Malassezia folliculitis and can serve as a office based tool for identification of this entity (AU)

Skin manifestations of Pseudomonas aeruginosa infections.

PURPOSE OF REVIEW: Pseudomonas aeruginosa is an opportunistic pathogen with considerable morbidity and mortality, particularly in vulnerable hosts. Skin manifestations are common, either representing local inoculation or secondary skin seeding following bloodstream infections. As patients with various predisposing conditions are expanding, we sought to review the most recent published evidence regarding epidemiology, risk factors and diagnosis of skin manifestations of P. aeruginosa. RECENT FINDINGS: New data exist on epidemiology and diagnosis of skin infections; systemic infections are impacted by multidrug-resistance issues and host immune status. SUMMARY: Green nail syndrome, toe web infection, hot tub folliculitis, hot hand-foot infection and external otitis are the most common infections originating from the skin per se. Local treatments are the cornerstone and prognosis is favorable in immunocompetent hosts. Ecthyma gangrenosum and P. aeruginosa subcutaneous nodules are usually associated with bloodstream infections and occur primarily in immunocompromised hosts. Necrotizing skin and soft tissue infections occur in diabetic, alcoholic and immunocompromised patients; management requires a multidisciplinary team with surgical approach. Burn wound infections may also be challenging, requiring a specialized team. In all the four latter types of P. aeruginosa skin infections portending significant morbidity and mortality, systemic antibiotics are an integral part of the treatment.

Aseptic Folliculitis in Freshwater and Marine Fishermen.

Folliculitis is a common skin disease, usually benign, which causes inflammation and eventual infections of hair follicles. They may have an infectious etiology, mainly due to the bacteria Staphylococcus aureus; it also occurs due to localized irritation, such as in areas of skin friction and for long periods of immersion in water, as in athletes and workers who are continuously exposed to the aquatic environment. Herein, we report on two fishermen, from fluvial and maritime environments, who presented with chronic aseptic folliculitis associated with daily immersion of their lower extremities while exercising the profession and that regressed when there was a decrease in their contact with water.

Gram-negative infections in patients with folliculitis decalvans: a subset of patients requiring alternative treatment.

Background Folliculitis decalvans is a neutrophilic cicatricial alopecia whose etiology remains unknown. It is frequently associated with staphylococcal infections. We aimed to determine the rate of gram-negative infections in patients with folliculitis decalvans. Methods A retrospective chart review was performed of patients with biopsy-proven folliculitis decalvans seen at a tertiary hair referral center. The results of bacterial cultures were evaluated. Subjects were determined to have no infection, gram-positive infections, gram-negative infections, or mixed infections. Results Thirty-nine subjects were included in the study. Ninety-three cultures were performed. The majority of cultures were positive for staphylococci. Eleven patients (28%) had gram-negative infections of the scalp. Gram-negative infections comprised one-third of all cultures (33%). Conclusion We present the largest cohort of folliculitis decalvans patients with gram-negative infections, suggesting the need for routine bacterial cultures in patients who are not responsive to standard anti-staphylococcal antibiotics. Awareness of the incidence of these infections may lead to better therapeutic outcomes.

Molecular epidemiology, in vitro susceptibility and exoenzyme screening of Malassezia clinical isolates.

Introduction. Malassezia folliculitis (MF) and pityriasis versicolor (PV) are common dermatoses caused by Malassezia species. Their molecular epidemiology, drug susceptibility and exoenzymes are rarely reported in China.Aim. To investigate the molecular epidemiology, drug susceptibility and enzymatic profile of Malassezia clinical isolates.Methodology. Malassezia strains were recovered from MF and PV patients and healthy subjects (HS) and identified by sequencing analysis. The minimum inhibitory concentrations (MICs) of nine antifungals (posaconazole, voriconazole, itraconazole, fluconazole, ketoconazole, miconazole, bifonazole, terbinafine and caspofungin) and tacrolimus, the interactions between three antifungals (itraconazole, ketoconazole and terbinafine) and tacrolimus, and the extracellular enzyme profile were evaluated using broth and checkerboard microdilution and the Api-Zym system, respectively.Results. Among 392 Malassezia isolates from 729 subjects (289 MF, 218 PV and 222 HS), Malassezia furfur and Malassezia globosa accounted for 67.86 and 18.88 %, respectively. M. furfur was the major species in MF and PV patients and HS. Among 60M. furfur and 50M. globosa strains, the MICs for itraconazole, posaconazole, voriconazole and ketoconazole were <1 µg ml-1. M. furfur was more susceptible to itraconazole, terbinafine and bifonazole but tolerant to miconazole compared with M. globosa (P<0.05). Synergistic effects between terbinafine and itraconazole or between tacrolimus and itraconazole, ketoconazole or terbinafine occurred in 6, 7, 6 and 9 out of 37 strains, respectively. Phosphatases, lipases and proteases were mainly secreted in 51 isolates.Conclusions. Itraconazole, posaconazole, voriconazole and ketoconazole are theagents against which there is greatest susceptibility. Synergistic effects between terbinafine and itraconazole or tacrolimas and antifungals may be irrelevant to clinical application. Overproduction of lipases could enhance the skin inhabitation of M. furfur.

Folliculitis decalvans is characterized by a persistent, abnormal subepidermal microbiota.

Folliculitis decalvans (FD) is a chronic inflammatory disease of unknown aetiology. Although Staphylococcus aureus, frequently found on lesional skin, is thought to play a causal role, the importance of its involvement remains controversial. To examine the role of S aureus, we compared superficial and subepidermal microbiota in 20 FD patients who had S aureus on lesional skin and in 20 healthy controls using culture techniques and genomic identification, before and after an anti-staphylococcal treatment; we also screened for S aureus virulence factors. When present on lesional skin, S aureus colonized non-lesional and subepidermal skin in 80% of cases. These data imply a break in the epidermal barrier integrity and that an abnormal non-lesional skin microbiota persists in FD. S aureus had no superantigenic toxin in 31% of cases and no toxin specificity. Clinical improvement obtained in most cases upon treatment was associated with the disappearance of S aureus in all studied areas, with an incomplete restoration of normal microbiota and a significant increase in negative bacterial samples. This persistent unbalanced, subepidermal microbiota may act as a reservoir of abnormal flora and explain the chronicity of FD, suggesting new avenues of research to restore normal microbiota.

[Acute generalized pustular bacterid followed by Sweet's syndrome and erythema nodosum]. / Pustulose aiguë généralisée post-streptococcique suivie d'un syndrome de Sweet et d'un érythème noueux.

INTRODUCTION: Streptococcal infections can cause various skin manifestations related to the direct action of the offending organism itself or to a reactional mechanism. Reactional manifestations are less well known and understood, and they include generalized acute pustulosis belonging to the spectrum of neutrophilic dermatoses. We report a case of generalized acute pustulosis followed by Sweet syndrome and erythema nodosum occurring after a streptococcal infection. PATIENTS AND METHODS: A 60-year-old woman was consulting for a diffuse pustular rash after a throat infection, with high levels of anti-streptolysin (337 U/L) and anti-streptodornase (2560 U/L). The biopsy showed folliculitis and a neutrophilic infiltrator of the dermis, and bacteriological and mycological cultures were sterile. The patient then developed papules evoking Sweet syndrome followed by nodules typical of erythema nodosum after 20 days. A favourable outcome was achieved under colchicine. DISCUSSION: Generalized acute pustulosis is a form of neutrophilic dermatosis whose mechanisms, area predilection and treatment are poorly known. The clinical presentation of this patient was initially typical and the secondary progression to lesions like those in Sweet syndrome is consistent with the pathophysiological continuity and overlap of these entities.

Clinical features and treatment of epidermal growth factor inhibitor-related late-phase papulopustular rash.

Papulopustular rash, an acneiform rash, appears on the seborrheic region during the first to second week of treatment with an epidermal growth factor receptor inhibitor (EGFRi). The rash gradually disappears after the fourth week; however, it persists or newly develops in other regions during EGFRi treatment. Because Staphylococcus aureus is frequently isolated from late-phase papulopustular rash, we assessed the incidence of bacterial infection and treatment outcomes of patients with late-phase papulopustular rash. Sixty-four cases treated with an EGFRi over 4 weeks who presented with papulopustular rash were assessed retrospectively. The median duration of EGFR inhibitor treatment was 5 months. Grade 2 and 3 papulopustular rash was observed in 47 and eight cases, respectively. Bacterial culture was performed in 51 cases, 50 of which yielded positive results: methicillin-sensitive S. aureus in 29, methicillin-resistant S. aureus in 14, Staphylococcus species in five, Pseudomonas aeruginosa in three, and other in four cases. Of the S. aureus isolates, 42% were resistant to minocycline and 40% to levofloxacin. After treatment with topical and/or oral antibiotics without topical corticosteroids, the papulopustular rash rapidly improved by an average of 2.9 ± 3.4 weeks. However, use of a combination of antibiotics and a topical corticosteroid prolonged the recovery period to an average of 18.9 ± 11.4 weeks. In conclusion, folliculitis that develops over 4 weeks after the initiation of EGFRi treatment is typically caused by staphylococcal infection. Bacterial culture is necessary due to the high rate of antibiotic resistance. It is important to distinguish late- from early-phase papulopustular rash and to treat using different approaches.

Folliculitis decalvans-like pustular plaques on the limbs sparing the scalp.

Folliculitis decalvans is a neutrophilic cicatricial alopecia characterised by progressive pustular folliculitis. Folliculitis decalvans is seen as a condition usually limited exclusively to the scalp and rarely affects the limbs. We present a case of a 63-year-old man with a 3-year history of progressive pustular folliculitis with inflammatory patches and central scarring alopecia on both forearms and a circumscribed patch on his right lower leg. His presentation, clinical course and isolation of Staphylococcus aureus together with the histopathological findings all supported a folliculitis decalvans-like pustular folliculitis limited to the limbs. Biopsies revealed follicular pustules, gross interfollicular fibrosis with plasma cells and concentric perifollicular fibrosis with lymphocytes, all features seen with folliculitis decalvans. The positive response to antibiotics combined with topical corticosteroids mirrored the response seen with scalp folliculitis decalvans. In contrast to the previously reported cases, the patient had no evidence of folliculitis decalvans on the scalp.

Clinicopathological differentiation between Pityrosporum folliculitis and acneiform eruption.

Distinguishing between Malassezia folliculitis (Pityrosporum folliculitis [P. folliculitis]) and acneiform eruption, based on clinicopathological features, is challenging for clinicians. In the literature, the histopathological differences between P. folliculitis and acneiform eruption lesions have been poorly described. We aimed to determine the clinicopathologic distinctions between P. folliculitis and acneiform eruption by retrospectively analyzing the histology of hematoxylin and eosin stained tissue sections obtained from 52 patients diagnosed with these lesions. The presence of fungal spores in the follicular lumen was most consistent with a P. folliculitis diagnosis (P < 0.001). However, intrafollicular inflammation (P = 0.009), irregular patterns of keratin plugging (P = 0.008), and nuclear dust in the follicular lumen (P < 0.001) favored an acneiform eruption diagnosis. These intrafollicular characteristics and inflammatory differences are believed to be caused by necrotic keratinocytes that lead to vacuolar changes in the follicular wall (P = 0.013). We did not observe any difference between P. folliculitis and acneiform eruption lesions in terms of perifollicular inflammatory cell infiltration. Our study demonstrated that significant differences exist between P. folliculitis and acneiform eruption lesions relative to the presence of necrotic keratinocytes in the follicular wall, intrafollicular characteristics, and inflammatory cell infiltrations. Necrotic keratinocytes are believed to have a key role in these differences. These findings may contribute to an improved understanding of the pathogenesis and differential diagnosis of P. folliculitis and acneiform eruption.