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Utility of Gram staining for diagnosis of Malassezia folliculitis
Wei-Ting TU,1 Szu-Ying CHIN,1,2 Chia-Lun CHOU,1,3 Che-Yuan HSU,1 Yu-Tsung CHEN,1
Donald LIU,1 Woan-Ruoh LEE,1,3,4 Yi-Hsien SHIH1,3,4
Departments of 1Dermatology, 2Pathology, Taipei Medical University Shuang Ho Hospital, New Taipei City, 3Department of
Dermatology, School of Medicine, 4Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei,
Taiwan
ABSTRACT
Malassezia folliculitis (MalF) mimics acne vulgaris and bacterial folliculitis in clinical presentations. The role of
Gram staining in rapid diagnosis of MalF has not been well studied. In our study, 32 patients were included to
investigate the utility of Gram staining for MalF diagnosis. The final diagnoses of MalF were determined according
to clinical presentation, pathological result and treatment response to antifungal agents. Our results show that
the sensitivity and specificity of Gram staining are 84.6% and 100%, respectively. In conclusion, Gram staining is
a rapid, non-invasive, sensitive and specific method for MalF diagnosis.
Key words: acne vulgaris, bacterial folliculitis, Gram staining, Malassezia folliculitis, Pityrosporum folliculitis.
Correspondence: Yi-Hsien Shih, M.D., Department of Dermatology, Taipei Medical University Shuang Ho Hospital, 291 Zhongzheng Road,
Zhonghe District, New Taipei City 23561, Taiwan. Email: 13263@s.tmu.edu.tw
Received 7 March 2017; accepted 5 October 2017.
diagnosis. If routine hematoxylin–eosin staining failed to agents.13 Bacterial folliculitis and mixed folliculitis were diag-
demonstrate any pathogen, PAS staining and Gram staining nosed mutatis mutandis. If final diagnosis remained undeter-
were performed to increase sensitivity. mined, the case was excluded.
Figure 1. Representative photographs and microscopic images of patients with (a) Malassezia folliculitis (middle, Gram staining,
original magnification 91000; right, periodic acid-Schiff performed on a paraffin block section, 91000), (b) bacterial folliculitis
(middle, Gram staining, 91000; right, Gram staining performed on a paraffin block section, 91000) and (c) mixed folliculitis (middle,
Gram staining, 91000; right, Gram staining performed on a paraffin block section, 91000).
Few studies have evaluated the accuracy of special staining to demonstrate the diagnostic accuracy of Gram staining for
smears in MalF diagnosis and the results were conflicting, MalF. We provided clear instructions about the number of
showing positive rates ranging 44–100%.1,4,5 Diagnosis of MalF sampled hair follicles and the definition of positive Gram stain-
by Gram staining was first reported by Lim et al.5,12 In their ing used in our study. In addition, we not only focused on clini-
epidemiological study, the authors claimed that the positive cal characteristics and epidemiological data, but also followed
rates of Gram staining and skin biopsy were 44% and 84%, treatment responses to exclude false-positive cases caused by
respectively. However, they did not mention patients’ treatment commensal Malassezia.
responses and thus false-positive cases caused by commensal Parker blue ink staining had been proposed for MalF diag-
Malassezia could not be totally excluded. Our study is the first nosis by Abdel-Razek et al.1 They reported 100% positive
rate of skin scrapings in all MalF patients, which was much 2 Durdu M, Guran M, Ilkit M. Epidemiological characteristics of Malas-
higher than what we observed in our study using Gram stain- sezia folliculitis and use of the May-Grunwald-Giemsa stain to diag-
nose the infection. Diagn Microbiol Infect Dis 2013; 76: 450–457.
ing. However, 10 out of 62 patients (16%) in their study had
3 Jacinto-Jamora S, Tamesis J, Katigbak ML. Pityrosporum folliculitis
only one single blastospore in the skin scrapings, which may in the Philippines: diagnosis, prevalence, and management. J Am
not be sufficient for the diagnosis of MalF, and only 24% Acad Dermatol 1991; 24: 693–696.
patients had skin biopsy proofs. A more recent study used 4 Levy A, Feuilhade de Chauvin M, Dubertret L, Morel P, Flageul B.
[Malassezia folliculitis: characteristics and therapeutic response in
MGG staining for MalF diagnosis.4 In this study, MGG stain-
26 patients]. Ann Dermatol Venereol 2007; 134: 823–828.
ing smear was more often positive than histology (89% vs 5 Lim KB, Giam YC, Tan T. The epidemiology of Malassezia
33%). Importantly, the end-points of both studies are the (Pityrosporon) folliculitis in Singapore. Int J Dermatol 1987; 26: 438–
treatment responses to different regimens for MalF, but not 441.
the sensitivity and specificity of special staining smears for 6 Gupta AK, Batra R, Bluhm R, et al. Skin diseases associated with
Malassezia species. J Am Acad Dermatol 2004; 51: 785–798.
MalF diagnosis. In our study, we compared the Gram staining
7 Harada K, Saito M, Sugita T, et al. Malassezia species and their
diagnoses to the final diagnoses made by standard diagnostic associated skin diseases. J Dermatol 2015; 42: 250–257.
criteria, and thus accurate sensitivity and specificity could be 8 Rubenstein RM, Malerich SA. Malassezia (pityrosporum) folliculitis. J
calculated. Clin Aesthet Dermatol 2014; 7: 37–41.
9 Akaza N, Akamatsu H, Numata S, et al. Microorganisms inhabiting
Interestingly, we were able to find eight cases of mixed folli-
follicular contents of facial acne are not only Propionibacterium but
culitis with coexistence of bacteria and Malassezia using Gram also Malassezia spp. J Dermatol 2016; 43: 906–911.
staining. The bacteria we found were Gram-positive bacilli or 10 Hald M, Arendrup MC, Svejgaard EL, et al. Evidence-based Danish
cocci in most cases. They were morphologically consistent guidelines for the treatment of Malassezia-related skin diseases.
with either Propionibacterium spp. or Staphylococcus spp. Acta Derm Venereol 2015; 95(1): 12–19.
11 Song HS, Kim SK, Kim YC. Comparison between Malassezia Folli-
Coexistence of Malassezia and Propionibacterium in acne
culitis and Non-Malassezia Folliculitis. Ann Dermatol 2014; 26: 598–
patients was reported recently by Akaza et al.9 In their study, 602.
they found that the severity of acne correlated with the number 12 Lim KB, Boey LP, Khatijah M. Gram’s-stained microscopy in the eti-
of Malassezia but not with that of Propionibacterium, suggest- ological diagnosis of Malassezia (Pityrosporon) folliculitis. Arch Der-
matol 1988; 124: 492.
ing Malassezia may participate in the pathophysiology of acne.
13 Prohic A, Jovovic Sadikovic T, Krupalija-Fazlic M, et al. Malassezia
In another Japanese single-center case series, approximately species in healthy skin and in dermatological conditions. Int J Der-
12% of acneiform eruptions were finally diagnosed as MalF.14 matol 2016; 55: 494–504.
In our study, many patients with mixed folliculitis under Gram 14 Suzuki C, Hase M, Shimoyama H, et al. Treatment Outcomes for
staining responded to antifungal agents significantly or at least Malassezia Folliculitis in the Dermatology Department of a University
Hospital in Japan. Med Mycol J 2016; 57(3): E63–E66.
partly.
Consequently, Gram staining is a rapid, simple and non-
invasive test for MalF diagnosis. Nevertheless, Gram staining SUPPORTING INFORMATION
does not reveal the location and invasion of pathogens as
clearly as histology does. The study is also limited by the lack Additional Supporting Information may be found in the online
of culture-based or molecular technique-based data. More version of this article:
research of larger sample size is required to validate the use of Data S1. Demographic characteristics and clinical presenta-
Gram staining for MalF diagnosis. tions of the included patients.
REFERENCES
1 Abdel-Razek M, Fadaly G, Abdel-Raheim M, et al. Pityrosporum
(Malassezia) folliculitis in Saudi Arabia–diagnosis and therapeutic
trials. Clin Exp Dermatol 1995; 20: 406–409.