A rare follicular variant of pityriasis versicolor

Dear Sir,

A 16-year-old female presented with a one-month history of asymptomatic multiple brownish lesions over the abdomen. On examination, there were three well- to ill-defined oval plaques with brownish follicular pigmentation over the abdomen [Figure 1a]. Dermoscopy showed perifollicular brownish pigmentation with whitish scales [Figure 1b]. Dermoscopic assisted extraction of scales was done, as scales were not visible on direct examination, and potassium hydroxide 10% examination showed the presence of multiple short hyphae and spores referred to as “spaghetti and meatballs” [Figure 1c] confirming Malassezia infection, so a diagnosis of follicular pityriasis versicolor was made. She responded to oral fluconazole 400 mg stat and topical luliconazole 1% cream twice daily for four weeks.

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Figure 1:

(a) Multiple brownish scaly macules present in a follicular distribution over the abdomen. (b) Dermoscopy (DermLite DL4; 4^th Gen; San Juan Capistrano, California, USA), noncontact polarized mode, ×10 magnification, showed perifollicular brownish pigmentation (red arrow) with whitish scales (black arrow). (c) KOH examination (×40) of skin scrapings showed the presence of multiple short hyphae and spores (black circle).

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Pityriasis versicolor caused by yeast of the genus Malassezia is a superficial chronically recurring fungal infection mainly caused by species globosa, restricta, and sympodialis.^[1] The various clinical variants of pityriasis versicolor that have been described include hypochromic, hyperchromic, combination of hypochromic and hyperchromic, circinate, erythematous, acral, blaschkoid, and atrophic, but localized follicular type has rarely been reported.^[1,2] Differentials in our case were follicular lichen planus pigmentosus, follicular eczema, and follicular pityriasis versicolor.

This case emphasizes the uncommon presentation of a rare variant of a prevalent skin condition, which may cause a diagnostic dilemma, but dermoscopy played an important role in the extraction of the imperceptible scales for microbiological examination and thus clinching the diagnosis.