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Co-occurrence of pityriasis versicolor and erythrasma: The importance of Wood’s lamp examination
V Ramesh1, Shanta Passi1, Ahmad Al Aboud2, Khalid Al Aboud3
1Department of Dermatology & STD, ESIC Medical College & Hospital, Faridabad (Hr), India, 2Dermatology Department, King Abdullah Medical City, Makkah, Saudi Arabia, 3Dermatology Department, King Faisal Hospital, Makkah, Saudi Arabia
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Sir,
Herein, we report the uncommon association of pityriasis versicolor (PV), a common mycosis, with erythrasma, a less recognized superficial bacterial infection of skin.
A nineteen-year-old adolescent boy came with asymptomatic, dark macules on the neck present for the previous one year, unassociated with other symptoms. On examination, oval to figurate macules with small, fine, flaky scales were seen on the lower neck extending to the nape (Fig. 1a). The lesions had slowly progressed in number and extent. A large, reddish macule with jagged borders and satellite macules were seen in both axillae, the striae being spared. A KOH examination of scrapings from the neck and axilla under direct microscopy showed numerous hyphae around clusters of spores in the former, while in the latter, short rods and coccoid forms, better appreciated in a Gram’s stain, were seen. Wood’s lamp examination revealed pale, yellow fluorescence in the neck and coral-red in the axilla (Fig. 2a). Bright pink fluorescence was also seen in the inguinal areas, which showed a faint pink and hyperpigmented macule (Fig. 1b), without any satellite lesions. The scrotal skin of one side also fluoresced (Fig. 2b). The gluteal and interdigital areas of the feet were normal and no fluorescence was observed. A diagnosis of PV with erythrasma was established. Oral fluconazole 400 mg stat, repeated after a week along with topical luliconazole, was given for the neck, and topical clindamycin was given for the axillae and inguinal areas. After two weeks, the lesions regressed and the patient was asked to continue topical therapy till the end of the month.
Both PV and erythrasma are infections limited to the stratum corneum caused by lipophilic organisms, the former by fungi belonging to the genus Malassezia and the latter by aerobic corynebacteria, usually Corynebacterium minutissimum. Differentiating them when they occur together becomes significant since antifungal drugs are indicated in PV and erythrasma responds best to antibacterials. They often cause no symptoms apart from cosmetic disfigurement and are common in the tropics where humidity with increased sweating prevails. PV is a recurrent condition affecting young adults, presenting as macules variably present on the upper trunk, neck, shoulders, and arms [1]. It is from these areas that PV extends into the flexural sites. Around 12% of patients with PV may have only flexural involvement, with the axillae and groin being the least preferred sites [2]. The hypopigmented form of PV is the most common [3,4], an infrequent association being seborrheic dermatitis of the scalp caused by the same organism [3]. The uncommon presentations may be red macules or dark-colored as in our case, also called PV nigra; these forms are interconvertible and more than one may at times be present in the same patient [1]. Interestingly, both PV and erythrasma may affect the same flexural site, casting doubt on the existence of the erythrasmoid variant of PV [5].
In our patient, the macules on the neck had fine, dark, branny scales, while the axillary lesions that went unnoticed by the patient were dull red. Direct microscopy and Wood’s lamp examination clearly established the diagnosis of PV nigra with erythrasma. Coral-red fluorescence was also noted in the inguinal area. The lesion here was fainter than that in the axillae and could have been mistaken for normal hyperpigmentation if not exposed to Wood’s lamp. Notably, the scrotal skin of one side in close apposition to the affected site also fluoresced, an observation hitherto undocumented. Occasionally fluorescence may be absent in PV caused by non-fluorescent pieces of Malassezia [1], which is when direct microscopy becomes important.
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The examination of the patient was conducted according to the principles of the Declaration of Helsinki.
The authors certify that they have obtained all appropriate patient consent forms, in which the patients gave their consent for images and other clinical information to be included in the journal. The patients understand that their names and initials will not be published and due effort will be made to conceal their identity, but that anonymity cannot be guaranteed.
REFERENCES
1. Crespo-ErchigaV, Florencio DV. Malassezia yeasts and pityriasis versicolor. Curr Opin Infect Dis. 2006;19:139-47.
2. Aljabre SHM. Intertriginous lesions in pityriasis versicolor. J Eur Acad Dermatol Venereol. 2003;17:659-62.
3. Rao GS, Kuruvilla M, Kumar P, Vinod V. Clinico-epidermiological studies on tinea versicolor. Indian J Dermatol Venereol Leprol. 2002;68:208-9.
4. Sreelakshmi S, Ajith V, Thankappan TP. Clinical and mycological study of pityriasis versicolor in relation to species. Int J Trop Dis Hlth. 2018;31:1-6.
5. Karakatsanis G, Vakirlis E, Kastoridou C, Devliotou-Panagiotidou D. Coexistence of pityriasis versicolor and erythrasma. Mycoses. 2004;47:343-5.
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