Letters to the Editor
To The Editors:
A premature (32 + 3 weeks gestational age) black skinned neonate with low birthweight (852 g) was placed in an incubator at the intensive care unit. The infant was receiving total parenteral nutrition (TPN) and broad spectrum antibiotics. He was examined for noncongenital depigmented areas at the age of 3 weeks. Physical examination revealed numerous hypopigmented macules and patches on the upper part of the trunk, face and neck (see Fig., Supplemental Digital Content 1, http://links.lww.com/INF/C25) where no lesions had been previously present. A fine scale was demonstrable when the surface of a lesion was scraped. Clinical examination of the parents did not reveal any skin eruption. The potassium hydroxide preparation demonstrated spherical yeast forms and hyphae. These characteristic findings supported the clinical diagnosis of pityriasis versicolor (PV). No specific cultures or polymerase chain reaction techniques were performed. He was treated with intravenous fluconazole for 2 weeks with total resolution of the lesions on follow-up after 3 months with no postinflammatory hypopigmentation.
Colonization by Malassezia in neonates begins in the first days of life, and increases during the first weeks.1 The mother seems to be the reservoir for the child’s colonization.2Malassezia furfur, M. sympodalis and M. globosa are the most common colonizing species. Molecular analysis has proven that M. globosa produces PV.
PV is characterized by multiple oval to round hypo- or hyperpigmented patches or thin plaques that are covered with fine scales. The lesions are often confluent and preferentially distributed in the seborrheic areas of the skin surface. In children, it often involves the face, in contrast to the rarity of facial involvement in adults. Typical PV has rarely been reported in neonates. Pityriasis alba, tuberous sclerosis and postinflammatory hypopigmentation are the main differential diagnoses.
Factors associated with risk of neonatal infection by Malassezia include genetic inheritance, gestational age, birth weight, length of stay in an intensive care unit, use of TPN, use of antibiotics, use of corticosteroids, elevated temperature and humidity of the incubator and the presence of central venous catheters.3
Potentially severe fungemia has been reported in association with M. sympodalis, M. furfur and M. pachydermatis in infants receiving TPN via an indwelling central venous catheter,4 but in none of these cases were skin lesions suggestive of PV were described. Studies investigating the colonization of central venous lines specifically by Malassezia spp. have demonstrated colonization rates of 2.4–32% in critically ill neonates.5 It is suggested that the organism is introduced into the nursery on the hands of health care workers. The clinical signs and symptoms of Malassezia fungemia and sepsis are fever and respiratory distress that can result in pneumonia or bronchopneumonia with an interstitial pattern on chest radiology.
PV is usually treated with topical antimycotic drugs. Systemic treatment with different oral antifungals, such as ketoconazole, itraconazole and fluconazole may be an option in extensive lesions and in those patients at risk of invasive disease, as in our case.
Elisabet Jubert, MD
Ana Martín-Santiago, MD
Department of Dermatology
Marta Bernardino, MD
Department of Pediatrics
Ana Bauzá, MD
Department of Dermatology
Hospital Universitari Son Espases
Palma de Mallorca, Spain
1. Bernier V, Weill FX, Hirigoyen V, et al. Skin colonization by Malassezia Species in Neonates. Arch Dermatol. 2002;138:215–218
2. Nagata R, Nagano H, Ogishima D, et al. Transmission of the major skin microbiota, Malassezia, from mother to neonate. Pediatr Int. 2012;54:350–355
3. Ahtonen P, Lehtonen OP, Kero P, et al. Malassezia furfur colonization of neonates in an intensive care unit. Mycoses. 1990;33:543–547
4. Gaitanis G, Magiatis P, Hantschke M, et al. The Malassezia genus in skin and systemic diseases. Clin Microbiol Rev. 2012;25:106–141
5. Aschner JL, Punsalang A Jr, Maniscalco WM, et al. Percutaneous central venous catheter colonization with Malassezia furfur: incidence and clinical significance. Pediatrics. 1987;80:535–539