Dermatopathology
Atrophying pityriasis versicolor as an idiosyncratic T cell–mediated response to Malassezia: A case series

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Background

Atrophying pityriasis versicolor (PV), first described in 1971, is a rare variant in which lesions appear atrophic.

Objective

We sought to determine the pathophysiology of atrophying PV.

Methods

A retrospective chart review identified 6 cases of atrophying PV. In all cases, routine light microscopy, an elastic tissue stain, and immunohistochemical assessment for the expression of CD3, CD4, CD8, GATA3 and CXCR3 was performed.

Results

All cases demonstrated hyperkeratosis with intracorneal infiltration by pathogenic hyphal forms as well as epidermal attenuation and papillary dermal elastolysis. A supervening, mild-to-moderate, superficial lymphocytic infiltrate was noted and characterized by a focal CD8+ T cell–mediated interface dermatitis along with a mixed T–cell infiltrate composed of GATA3+ and CXCR3+ T cells.

Limitations

Small sample size and the loss of some patients to follow-up.

Conclusion

Atrophying PV represents the sequelae of a mixed helper T–cell (TH1 and TH2) idiosyncratic immune response to Malassezia and can present as a protracted dermatosis that may clinically mimic an atypical lymphocytic infiltrate. TH1 cytokines can recruit histiocytes, a source of elastases, and upregulate matrix metalloproteinase activity, which may contribute to epidermal atrophy.

Section snippets

Materials and methods

Six cases diagnosed as atrophying PV were uncovered in the database of one of the authors over the time period of July 2006 to October 2015. In each case, a detailed clinical history was obtained. Follow-up was also attempted on these cases. Five cases of typical PV without atrophy were also drawn from the database to represent control cases. Biopsy material was available for routine light microscopic assessment. In each case, a Verhoeff-van Gieson stain was conducted as well as a limited

Case synopsis

Case 1: A 56-year-old man who was otherwise healthy presented with a 2-year history of asymptomatic, yellowish-brown, slightly atrophic patches in the right axilla. There was no prior treatment of these lesions. The clinical differential diagnosis included PV, erythrasma, and patch stage mycosis fungoides. A diagnosis was made of atrophying PV after which the patient was treated with a single dose of ketoconazole 400 mg orally as well as topical ketoconazole cream. The atrophic lesions were

Discussion

A rare variant of PV that is becoming increasingly recognized is atrophying PV. A review of the literature was conducted by searching the PubMed, MEDLINE, and EMBASE databases, as well as reviewing articles cited in relevant research studies, revealing 23 studies describing cases of atrophying PV.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 Including the 6 cases reported in our series, there have now been at least 43 cases of atrophying PV reported in the

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    Support for Jonathan Levy's elective rotation at Weill Cornell Medicine came from a Canadian Dermatology Foundation Kalz bursary. This research otherwise has no funding sources.

    Conflicts of interest: None declared.

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    © 2016 by the American Academy of Dermatology, Inc.