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| CORRESPONDENCE |
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| Year : 2021 | Volume
: 39
| Issue : 2 | Page : 83-84 |
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Atrophying pityriasis versicolor: A rare variant with review of literature
Ya-Min Chang1, Po-Yuan Wu2
1 Department of Dermatology, China Medical University Hospital, China Medical University, Taichung, Taiwan
2 Department of Dermatology, China Medical University Hospital, China Medical University; Department of Dermatology, School of Medicine, China Medical University, Taichung, Taiwan
| Date of Submission | 20-Mar-2020 |
| Date of Decision | 11-Jan-2021 |
| Date of Acceptance | 21-Jan-2021 |
| Date of Web Publication | 23-Jun-2021 |
Correspondence Address:
Dr. Po-Yuan Wu
Department of Dermatology, China Medical University Hospital, No. 2, Yuh Der Road, Taichung 404
Taiwan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ds.ds_3_21
How to cite this article:
Chang YM, Wu PY. Atrophying pityriasis versicolor: A rare variant with review of literature. Dermatol Sin 2021;39:83-4 |
Dear Editor,
Pityriasis versicolor is a superficial fungal infection caused by Malassezia species and characterized by roundish to oval maculopatches varying in color from hypopigmentation to red to hyperpigmentation. The typical locations usually involved are the upper trunk, neck, and upper arms. However, rare cases present with atrophic patches, which might be misdiagnosed as other diseases that cause skin atrophy, such as atrophoderma of Pasini and Pierini. We herein report a case of pityriasis versicolor with cutaneous atrophy.
A 54-year-old woman presented with pruritic atrophic erythematous plaques involving her back for several months. There was no history of systemic disease or other skin problems; she took no medications and was in good health. She went to a local clinic and was initially treated with topical corticosteroid for about 1 month, with no improvement. On examination, there were multiple erythematous, slightly scaly, depressed plaques, which were scattered or confluent on the back with lower back predominance [Figure 1]a. | Figure 1: (a) Multiple erythematous, slightly scaly, depressed plaques, which were scattered or confluent on the back with lower back predominance. (b) Atrophic lesions moderately improved with topical ketoconazole 2% cream after 5 months.
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Skin scrapings from these areas were examined microscopically using potassium hydroxide (KOH) preparation that showed numerous short hyphae and spores. Histological examination revealed flattening of the rete ridges and multiple fungal hyphae and spores at stratum corneum [Figure 2]a and [Figure 2]b with Grocott methenamine silver stain positive [Figure 2]c. Some dilated blood vessels are located in the upper dermis [Figure 2]a. Fragmented elastic fibers within the dermis were highlighted by the Verhoeff–Van Gieson stain [Figure 2]d. With these findings, a diagnosis of atrophying pityriasis versicolor was made. The patient was treated with topical ketoconazole 2% cream twice daily and the lesions moderately improved [Figure 1]b with negative KOH test results during 5 months' follow-up. | Figure 2: Flattening of the rete ridges and multiple fungal hyphae and spores at stratum corneum with Grocott methenamine silver stain positive. Some dilated blood vessels in the upper dermis. Fragmented elastic fibers within the dermis highlighted by the Verhoeff–Van Gieson stain ([a] H and E staining,×100; [b] H and E staining,×400; [c] Grocott methenamine silver stain,×400; [d] Verhoeff–Van Gieson stain,×100).
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Superficial fungal infection presenting with atrophic skin lesions was rarely reported. A few published cases were pityriasis versicolor caused by Malassezia species.[1],[2],[3],[4],[5] Classical pityriasis versicolor is most commonly seen in young adults with oval to roundish slightly scaly maculopatches varying in color usually involving the upper trunk, neck, and upper arms.[6] Atrophying pityriasis versicolor occurring in an older age, range from 17 years to 74 years old with the median around 50 years old and also usually involving the typical locations as classical pityriasis versicolor.[1],[3],[4],[5] There is a lower back predominance in our case as distinct from classical and previously reported atrophying pityriasis versicolor. The exact pathophysiology remains unknown. Tatnall and Rycroft hypothesized that the skin barrier is disrupted by pityriasis versicolor, allowing better absorption of the steroid, which induces atrophy.[2] Crowson and Magro conducted clinical and histological studies in 12 patients with atrophying pityriasis versicolor, however, only one used topical steroids chronically, proposed that delayed hypersensitivity reactions to antigens derived from components of the Malassezia yeast colonizing the epidermal surface and hair follicle orifices or the direct effect of Malassezia on nuclear factor kappa B signaling causing atrophying pityriasis versicolor.[3] Levy and Magro reviewed 6 cases of atrophying pityriasis versicolor proposed that type IV hypersensitivity reaction driven by mixed TH1/TH2 immune response to Malassezia, and TH1 cytokines contribute to atrophy and elastolysis mainly by upregulation of matrix metalloproteinase activity.[7] Histopathologic features reveal epidermal colonization with pityrosporum hyphae and spores accompanied by variable epidermal atrophy, dermal atrophy, dermal elastolysis, and superficial perivascular lymphocytic infiltrate.[3],[7] The histopathological difference between steroid atrophy and atrophying pityriasis versicolor is that corticosteroid-induced atrophy is associated with profound epidermal atrophy, telangiectasias, and attenuation in the collagen framework. In atrophying pityriasis versicolor, there is dermal elastolysis contributing to the occurrence of skin atrophy.[7] In our case, although skin biopsy showed rete ridge flattening, telangiectasia and few inflammatory cell infiltrates in the upper dermis may relate to topical steroid use, focal loss, and fragmented elastic fibers rather than reduction in collagen favoring atrophying pityriasis versicolor.
The clinical differential diagnoses of atrophying pityriasis versicolor included atrophoderma of Pasini and Pierini, anetoderma, morphea, parapsoriasis, mycosis fungoides, and sarcoidosis.[3] In our case, differential diagnosis can be narrowed down by the presence of fine scaling overlying the atrophic area clinically and characteristic hyphae and spores histologically.
Although atrophying pityriasis versicolor shared the same treatment regimens as classical pityriasis versicolor, a longer treatment period might be required for atrophying type.[1],[8] It was reported that 12 patients with atrophying pityriasis versicolor were treated with ketoconazole with clinical resolution of the cutaneous atrophying lesions.[3] Cases successfully treated with oral itraconazole 200 mg daily for 2–3 weeks showed improved atrophic lesions and mycological cure also be reported.[1],[4] Discontinuing the use of topical steroids if the patients have had a history of topical steroid use is important.[2],[8] Although treatments for extensive lesions are more often with oral antifungal agents, in our case a mycological recovery was achieved and the atrophic lesions gradually improved within approximately 5 months after the initiation of topical ketoconazole 2% cream treatment. Atrophying pityriasis versicolor shows a relatively good prognosis compared with other diseases that cause skin atrophy.
In conclusion, atrophying pityriasis versicolor should be considered in the differential diagnosis of atrophic lesions. This case illustrates the importance of microscopic examination of the skin scrapings using the KOH test for patients presenting scaly atrophic skin lesions, particularly in the setting of typical location such as the back.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Yang YS, Shin MK, Haw CR. Atrophying pityriasis versicolor: Is this a new variant of pityriasis versicolor? Ann Dermatol 2010;22:456-9.  |
| 2. | Tatnall FM, Rycroft RJ. Pityriasis versicolor with cutaneous atrophy induced by topical steroid application. Clin Exp Dermatol 1985;10:258-61. |
| 3. | Crowson AN, Magro CM. Atrophying tinea versicolor: A clinical and histological study of 12 patients. Int J Dermatol 2003;42:928-32. |
| 4. | Park JS, Chae IS, Kim IY, Ko DK, Chung H, Lee SW. Achromatic atrophic macules and patches of upper extremities. Indian J Dermatol Venereol Leprol 2013;79:270. [Full text] |
| 5. | Romano C, Maritati E, Ghilardi A, Miracco C, Mancianti F. A case of pityriasis versicolor atrophicans. Mycoses 2005;48:439-41. |
| 6. | Faergemann J, Fredriksson T. Tinea versicolor: Some new aspects on etiology, pathogenesis, and treatment. Int J Dermatol 1982;21:8-11. |
| 7. | Levy JM, Magro C. Atrophying pityriasis versicolor as an idiosyncratic T cell-mediated response to Malassezia: A case series. J Am Acad Dermatol 2017;76:730-5. |
| 8. | Gupta AK, Batra R, Bluhm R, Faergemann J. Pityriasis versicolor. Dermatol Clin 2003;21:413-29, v-vi. |
[Figure 1], [Figure 2]
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