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E-IJD CORRESPONDENCE
Year : 2015  |  Volume : 60  |  Issue : 3  |  Page : 324
Nipple hyperkeratosis due to malassezia furfur showing excellent response to itraconazole


Department of Dermatology, Villupuram Medical College, Tamil Nadu, India

Date of Web Publication6-May-2015

Correspondence Address:
Kumar Parimalam
Department of Dermatology, Villupuram Medical College, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.156474

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How to cite this article:
Parimalam K, Chandrakala C, Ananthi M, Karpagam B. Nipple hyperkeratosis due to malassezia furfur showing excellent response to itraconazole. Indian J Dermatol 2015;60:324

How to cite this URL:
Parimalam K, Chandrakala C, Ananthi M, Karpagam B. Nipple hyperkeratosis due to malassezia furfur showing excellent response to itraconazole. Indian J Dermatol [serial online] 2015 [cited 2021 Jul 26];60:324. Available from: https://www.e-ijd.org/text.asp?2015/60/3/324/156474


Sir,

Conditions like pityriasis versicolor, malassezia folliculitis, seborrheic dermatitis, atopic dermatitis, confluent and reticulated papillomatosis, psoriasis, onychomycosis, and transient acantholytic dermatoses have so far been reported to be caused by the yeast Malassezia. [1] Hyperkeratosis of the nipple is a rare manifestation of Malassezia furfur with few documented reports. [2] Levy-Franckel divided hyperkeratosis of the nipple and areola (HNA) into three categories. The first category is due to extension of epidermal nevus, the second, associated with other dermatoses like eczema, ichthyosis, acanthosis nigricans, or lymphoma. Third group is the idiopathic variant in which the histology may show Orthokeratotic hyperkeratosis, papillomatosis, mild acanthosis and dermal perivascular lymphocytic infiltrate. Histological features of epidermal nevus or acanthosis nigricans may be seen in types one and two, respectively. [3] We report a young woman with nipple hyperkeratosis due to M. furfur, which responded dramatically to oral itraconazole. A 23-year-old healthy unmarried lady presented with asymptomatic rough growth of both her nipples since 1 year. She was very much disturbed with the recurrent nature of the problem which did not completely resolve with various treatments like emollients, topical tretinoin and steroid. She was even suggested to undergo electro cautery which the patient was not willing for. On examination she had, dark brown, verrucous growth of both nipples [Figure 1] which was not removable with isopropyl alcohol. There were no features suggestive of pityriasis versicolor, pityrosporum folliculitis, seborrheic or atopic dermatitis, confluent and reticulated papillomatosis, psoriasis, onychomycosis, and transient acantholytic dermatoses, acanthosis nigricans or verruca. Verruca, terra firma-forme dermatosis, dermatoses neglecta and idiopathic nipple hyper keratosis were considered as differentials. Scraping with KOH examination showed spores and hyphae of M. furfur. After explaining to the patient a shave biopsy was done which showed massive hyperkeratosis with spores in the stratum corneum [Figure 2], [Figure 3], [Figure 4]. After confirming her liver status to be normal, she was treated with oral itraconazole 200 mg daily along with topical 2% Clotrimazole cream. The lesions cleared dramatically within 7 days of treatment [Figure 5]. Topical Clotrimazole was continued for 1 month. There has been no recurrence so far.
Figure 1: Dark brown, verrucous growth of nipples

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Figure 2: Massive hyperkeratosis with spores in the stratum corneum [H and E] ×100

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Figure 3: PAS stain showing spores in the stratum corneum ×100

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Figure 4: PAS stain showing spores in the stratum corneum ×400

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Figure 5: Seven days of treatment with antifungal therapy

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Dermatosis neglecta presents as desquamative, greasy, hyper chromic lesions that are easily removable; the pathological examination may reveal intense hyperkeratosis and spores. [4] The stable psychological status and willingness for therapy excluded the possibility of dermatoses neglecta in our case. The presence of spores excluded possibility of verruca. The absence of features of specific dermatological conditions histologically excluded HNA types one and two. Disappearance of lesion with antifungal therapy excluded idiopathic HNA which is resistant to treatment.

Hyperkeratosis of nipple is a very disturbing entity which can be a manifestation of various underlying pathologies including lymphoma. Apart from treatment of primary cause, the various other options available include topical application of lactic acid 12% cream, salicylic acid gel 6%, tretinoin, and calcipotriol and low-dose oral acitretin orally. Other modalities include, cryotherapy, laser, radiofrequency, excision and skin graft reconstruction. [5] Our case seems to be the first Indian report of hyperkeratosis of nipples which responded well to itraconazole. An improper keratinizing response to Malassezia could be the probable explanation in our case. Awareness of this entity and demonstration of fungal element is important to effectively treat this simple yet disturbing condition.

 
   References Top

1.
Gupta AK, Batra R, Bluhm R, Boekhout T, Dawson TL Jr. Skin diseases associated with Malassezia species. J Am Acad Dermatol 2004;51:785-98.  Back to cited text no. 1
    
2.
Li C, Ran Y, Sugita T, Zhang E, Xie Z, Cao L. Malassezia associated hyperkeratosis of the nipple in young females: Report of three cases. Indian J Dermatol Venereol Leprol 2014;80:78-80.  Back to cited text no. 2
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3.
Boussofara L, Akkari H, Saidi W, Ghariani N, Sriha B, Denguezli M, et al. Bilateral idiopathic hyperkeratosis of the nipple and areola. Acta Dermatovenerol Alp Pannonica Adriat 2011;20:41-3.  Back to cited text no. 3
    
4.
Boralevi F, Marco-Bonnet J, Lepreux S, Buzenet C, Couprie B, Taïeb A. Hyperkeratotic head and neck Malassezia dermatosis. Dermatology 2006;212:36-40.  Back to cited text no. 4
    
5.
Camacho ID. Hyperkeratosis of the Nipple and Areola Treatment and Management at Available from: http://www.emedicine.medscape.com/article/1107107-treatment seen on 1.4. 2014. [Last accessed on 2014 April 1].  Back to cited text no. 5
    

What is new?
Nipple hyperkeratosis caused by M. furfur is a new entity hitherto not reported in Indians. The dramatic response to antifungal therapy further proves the etiology.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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