A Survey on Pityriasis Versicolor in the University Students in Southeast of Iran
The present study was aimed to determine the prevalence
of pityriasis versicolor in the university students in Southeast of Iran.
Clinical examination conducted and Woods light (260-2600 A° UV light)
utilized on 800 volunteer students including 400 males and 400 females.
Consequently, the students presenting any macular lesion subjected to
further examinations including direct smears, sellotape and culture methods
for identification of Malassezia species. Pityriasis versicolor
was clinically determined in 159 (39.75%) male and 179 (44.75%) female
students. Woods light examination was positive with yellowish-golden
demonstration, in 32.5% of males and 39.5% of females, indicating the
involvement of Pityriasis versicolor and Malassezia species. Direct
examination and culture results demonstrated 84.50 and 80% positive, respectively.
The study confirmed a high prevalence of pityriasis versicolor in the
students living in university dormitories. This infection, therefore,
should be noted as an important public health problem in the study area,
particularly, where students live together. Also, the pathogenic consequences
of Malassezia species and its predominant involvement in pityriasis
versicolor should be considered.
Pityriasis Versicolor (PV) is a chronic or mild infection of the stratum corneum.
The lesion are characterized by a branny or furfuraceous consistency; they are
discrete or concrescent and appear as discolored or depigmented areas of the
skin. The affected areas are principally on the chest, abdomen, upper limbs
and back. The etiological agents are the lipophilic yeasts, Malassezia
species (Schwartz, 2004). Yeasts of the genus Malassezia
are known to be members of the skin microflora of human and other warm-blooded
vertebrates (Midgley et al., 1998; Leeming
et al., 1989). These lipophilic yeasts are associated (Gupta
et al., 2002), with various human diseases, especially PV, a chronic
superficial scaling dermatomycosis (Fitzpatrick and Johnson,
2001). This disease is common in late teens and young adults of both sex
and characterized by well-demarcated scaling patches with variable pigmentation
PV was described at the beginning of nineteen century (Eichstedt,
1846). The genus of Malassezia has undergone several taxonomic revisions
(Midgley et al., 1998). In the last reclassification
by Gueho et al. (1996) seven distinct species
were recognized within this genus, namely M. furfur, M. pachydermatis,
M. sympodialis, M. globosa, M. obtusa, M. restricta
and M. slooffiae. Recently, four more species have been identified,
M. dermatis, M. japonica, M. yamatoensis and M. nana
and M. furfur has long been identified as the causative fungus of PV
(Morishita et al., 2006).
Pityriasis versicolor (Tinea versicolor) has worldwide occurrence, its frequency
is variable and depends on different climatic, occupational and socio-economic
conditions (Borelli et al., 1991). PV has been
reported to be common in different communities, in particular the crowded places
like dormitories. It has been studied in a variety of different geographical
areas. Previous survey in Tehran-Iran showed high prevalence of PV, are due
to these lipophilic yeasts Tarazooie et al. (2004).
The present study was aimed to determine the prevalence of PV in the university
students in Southeast of Iran and identification of the causative agents, Malassezia
MATERIALS AND METHODS
Eight hundred university students, including 400 males and 400 females
accommodated in a number of university dormitories in Zahedan, Southeast
of Iran, were randomly in October 2006-2007 selected. A questionnaire
was used to collect the required information from every individual subject.
Consequently, the clinical observation, woods lamp test (260-2600 A°
UV light) and mycological examinations were performed to confirm the diagnosis
of pityriasis versicolor and the fungal species. Specimens were taken
by scraping the lesions with a sterile scalpel.
Direct microscopy with 20% KOH and methylene blue staining were carried out
for those with clinically assigned PV lesions. All samples were also inoculated
in plates containing modified Dixon medium. The plates were incubated at 31°C
for two weeks and examined at frequent intervals for observation of developing
colonies (Tarazooie et al., 2004). A number of
200 male and female students (100 each) who were shown healthy (without any
dermatosis) at physical observation, were also subjected to the mycological
examinations as described above. Superficial skin samples were taken by sellotape
from these normal students as well as the cases with no sufficient scales.
RESULTS AND DISCUSSION
The screening observation resulted in demonstration of pityriasis
versicolor in 42.25% of the 800 investigated students; it was 39.75% in
male and 44.75% in female students with no significant difference (Table
1). The Woods lamp test was positive (showing golden yellow) in 32.5%
of males and 39.5% of females, with no significant difference (Table
1). The most affected areas were the trunk and neck. The average age
of the students was 20±3 years. The highest prevalence of PV 60%
was seen in the student with 20-21 years of age. Misdiagnosis of PV demonstrated
7.25 and 5.25% in male and female by woods lamp test comparing to the
direct examination method. Direct examination and culture results of specimens
was positive in 84.5 and 80% yielded Malassezia species, respectively
(Table 2). A proportion of 86.5% of the positive specimens
from PV lesions, presented hyphae together with budding yeasts. The laboratory
examination of the specimens obtained from healthy students (control groups),
showed for direct examination and culture, 30% PV and 25% Malassezia
spp., respectively (16% females and 14% males).
The present study demonstrated a high prevalence of PV in the university students
in Zahedan, Southeast of Iran. There was no association between sex and the
rate of infection. This is similar to the results obtained from a previous survey
in Tehran, Iran, that showed a high prevalence of Pityriasis versicolor, in
which almost 6% of all dermatosis and approximately 30% of dermatomycoses were
found to be due to these lipophilic yeasts, Malassezia species (Tarazooie
et al., 2004). Although the Pityriasis versicolor is a worldwide
prevalent infection, it is variable in different areas and depends on climatic,
occupational and socio-economic conditions (Borelli et
||The rate of pityriasis versicolor infection in the university
students in Zahedan, Southeast of Iran
||The results of laboratory examination of pityriasis versicolor
cases screened from the university students in Zahedan, Southeast of Iran
The highest rate of PV infection was seen in the students aged 20-21 years.
The studied subjects were in a restricted range of ages (20±3 years) as they
were of the student community, but other investigations also had presented similar
results (Midgley et al., 1998; Crespo
Erchiga et al., 1999a; Gupta et al., 2001a;
Tarazooie et al., 2004), suggesting that the peak
of the infection is coincided with ages when the sebum production is in the
highest level. Although 60% of patients in age range of 10-20 years were female,
this proportion was reversed in the age group 20-30. Lower maturity age in female
compared with male can be considered as the possible reason of this dissimilarity.
Pityriasis versicolor is uncommon in children (Gupta et
The present study showed insignificant difference in PV infection between male
and female. The role of sex in propensity to development of PV is still unclear
and is the subject of discrepancy. Some studies found that PV is more common
in men (Belec et al., 1991; Nakabayashi
et al., 2000); whereas, others reported a higher incidence of the
infection in women (Crespo Erchiga et al., 1999b;
Gupta et al., 2001a, b;
Crespo Erchiga and Delgado Florencio, 2002; Gaitanis
et al., 2006), which may be due to extra attention of women to their
beauty and skin hygiene. Also there are reports indicating no significant differences
of PV between sexes (Crespo Erchiga et al., 1999a;
Fitzpatrick and Johnson, 2001; Gupta
et al., 2001a, b).
Although Malassezia species are considered as normal microflora of the
human skin, these lipophilic yeasts are associated with many skin disorders
in particular PV, in some circumstances. It is widely believed that endogenous
factors such as administration of corticosteroids, malnutrition and increased
plasma cortisol level are involved with the development of PV (Boardman
and Malkinson, 1962; Borelli et al., 1991;
Gupta et al., 2001a, b).
Besides, the role of high temperature and humidity in this condition is well
established (Faergemann, 1989; Midgley
et al., 1998). In this regard, no significant differences were observed
in culture results of students PV caused in comparison with controls. Similar
to other investigations (Ashbee and Evans, 2002; Gupta
et al., 2001a, b).
In this survey, the most affected areas were the trunk and neck, which is concordant
with most of the previous studies (Gupta et al., 2001a,
b). The distribution of Malassezia species on
back and chest is parallel with the density and activity of pilocebaceous glands
in these areas. Similar to previous studies (Gupta et
al., 2001b), we found no statistical difference in the distribution
of Malassezia species on various body sites.
Diagnosis of PV is generally simple and lies on the clinical manifestations
and microscopic examinations of the lesions (Crespo Erchiga
and Delgado Florencio, 2002). In the direct examination, 84.50% of PV samples
yielded positive results, which is the same as the results reported by Crespo
Erchiga et al. (1999b). Two cases with negative results in this study
had also been received topical antimycotic treatment. Significant difference
was obtained between the sensitivity of the preliminary test, woods lamp (72%)
and that of direct examination (84.50%). It can probably be attributed to the
condition of the subjects on the day of sampling, i.e., receiving antibiotic
treatment or possibly taking shower.
In 86.2% of positive cases of PV, classical feature so-called spaghetti and
meatball forms were seen. Present results are consistent with those previously
published and confirm the significance of the yeast-mycelium conversion in pathogenesis
of this infection (Crespo Erchiga et al., 2000;
Crespo Erchiga and Delgado Florencio, 2002; Crespo
Erchiga and Florencio, 2006). Regarding high sensitivity and acceptable
specificity of direct examination, diagnosis of PV is based on observation of
short hyphae and yeast in the scales. However, in cases that only hyphae were
presented in the scales, direct examination of samples with KOH, especially
by unskillful technicians, may fail to reveal the infection. Hence, we suggest
staining the scales prior to performing light microscopic examination to avoid
Culture is necessary to distinguish the Malassezia species by morphological
and physiological methods. In the present study, the recovery rate of Malassezia
species from the PV lesions was 80%, which was mostly comparable to recent study
by Nakabayashi et al. (2000). But, it was higher
than that of some previous studies (Midgley, 2000; Gupta
et al., 2001b; Sugita et al., 2001;
Dutta et al., 2002). The difference may be due
to the fact that margin of the PV lesions might be used to collect specimens.
However as it was shown by Crespo Erchiga et al. (2000)
unlike other dermatomycosis, center of the PV lesions yields more viable materials
for culture. Hence, we scraped center of the lesions instead of the borders
to increase recovery rate of the organism and avoid isolation of surrounding
commonsal species (Midgley, 2000; Crespo
Erchiga et al., 2000; Crespo Erchiga and Delgado
Malassezia species are members of the normal skin flora and can be recovered
from different sites of the body especially the sebaceous-rich areas. In healthy
skin, we found Malassezia species by direct examination and culture with
the frequency of 30 and 25%, respectively. These rates of positive results in
our study are lower than those from recent study of Gupta
et al. (2001a) and may suggest the difference in sampling method
and culture medium. In this survey, similar to other studies (Sugita
et al., 2001; Aspiroz et al., 2002;
Tarazooie et al., 2004).
It was concluded that pityriasis versicolor is highly prevalent in the
students living in university dormitories indicating an important public
health problem in the study area, particularly, where students live together.
Also, the pathogenic consequences of Malassezia species and its
predominant involvement in PV should be considered.
This project was granted by Deputy for Research at Zahedan Medical
Sciences University and Zahedan Azad University. The authors would like
to thank Dr. Tabatabai, the former head of Medical college in Zahedan
Azad University, for a generous support of this study.
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