PITYROSPORUM FOLLICULITIS From: "Okun, Martin" I have a patient in his mid-twenties, otherwise healthy, with quite marked pityrosporum folliculitis over much of his back, somewhat pruritic. He has refused topical treatment because of the extensive area of involvement. I have treated him with Ketoconazole 200 qDay X 15 days with marked improvement, but his lesions recurred after the Ketoconazole was D/C'ed. A prophylactic dose of Ketoconazole 200 Qday for 3 days per month was unable to quench the folliculitis. Because of the risk of hepatotoxicity, I am loathe to prescribe daily Ketoconzole for prologed periods. As I see it, I have two options: insist that he use topical treatment (Nizoral, or Selenium Sulfide), or try Itraconzole (my perspective is that Itraconazole is a bit of overkill for a fairly innocuous dermatosis). There is no medical literature that I have found regarding use of Itraconzole for pityrosporum. I would welcome other treatment suggestions, or advice regarding appropriate dosages for Itraconazole for pityrosporum folliculitis. Thanks in advance for your help. ============= From: SL Lamberg NIzoral po is the right choice but you will have to treat for at least 30 days at a BID dose. Usually there has been substantial clearance by that time but there will usually be reappearance of the PF unless a second 30 days at the same dose is prescribed. I've had only a few recurrences after that. PF does not respond to any topical measures I've tried, including Nizoral shampoo left on overnight. I discuss the liver issue but do not (but probably should) get LFTs. The rate of serious reactions is so low that it must be idiosyncratic and is not really predicted by small elevations in enzymes which are going to be common. PF is really quite common and in not recognized since I get numerous "acne treatment failures" from other dermatologists who were treating the eruption with systemic antibiotics, obviously contraproductive. One more thing, avoid systemic antibiotics for Rx of coexisting acne since the PF will return. You may end up using Accutane more frequently in such cases. ============= From: jayroth@azstarnet.com (James G. Rothschild) I would suggest using itraconazole 200mg. B.I.D. for the first week of each month for 4 consecutive months. I use this regimen routinely for onychomycosis without monitoring of LFTs. Itraconazole is less hepatotoxic than ketoconazole and intermittent use is very safe. I would only caution the patient about concurrent use of hismanal or seldane. At the same time I would recommend weekly showering with selenium sulfide 2.5% shampoo. This may decrease the pityrosporum organism on the skin. =============== From: Jerry Eisner I have had good results using Nizoral Shampoo as a topical agent. As you know, it is 2% strength, same as the cream, with the exception that you cannot leave it on the skin, since it contains detergents etc for the shampoo. I have the patient apply it daily for 5 days, leave it on 5 minutes and wash off. Then twice a week for at least a month. If they are clear, I suggest they use it twice a month or more, prophylactically. When I treat orally with Nizoral, I get them started on the shampoo at the same time, perhaps at twice a week until clear and continue with prophylactic use as above, indefinitely. ================= From: Daniel F Mitchell I use ZNP bar (Zn pyrithione soap) to reduce recurrences of T. versicolor. Might work to reduce recurrences in pityr. folliculitis, as well. Couldn't hurt. ============ From: Haines Ely Ketoconizole is soluble in acids(ie phosphoric acid in Coke). If you dissolve several tablets in household vinegar you have a nice topical solution. One can put the solution in a pump sprayer for application. Remember that Nizoral gets to the skin in sweat. The concentration sprayed on is quite high. The patient smells like a salad for a moment until the vinegar dries. Much cheaper than systemic Rx. (Great for tinea versicolor)Haines ELy, Grass ============== From: "Mark Naylor" For treatment of pityrosporon folliculitis I use either prolonged topical imidazoles (preferably twice daily for at least 6-8 weeks) or oral ketoconazole for at least six weeks (which is much more effective in my experience). The sensitivities of pityrosporon to itraconazole is not listed in the '95 PDR, but by word of mouth I have heard that pityrosporon is sensitive to Sproranox. My source on this is actually a conversation I had at a recent meeting with Don Printz. I have no personal experience using it in either tinea versicolor or pityrosporon folliculitis, but so far have found very little in the way of lab abnormalities or side effects using it in limited numbers of patients treated with pulse therapy for onychomycosis. Sorry about the anecdotal nature of this comment, but I don't believe there are any published studies supporting the use of Sporanox in pityrosporon folliculitis, although it might be effective. ======== From: "L.J. Gregg" <73477.361@compuserve.com> In a few such difficult cases I have had success with 7-10 day courses of diflucan 200 mg daily putting the condition in longer remission . ZNP bar by Steifel labs can be and easier and more pleasant prophylaxis since the patient can use it in the shower and it does not smell of sulphur. Many of my patients are vigorous exercisers and become quite symptomatic when they become sweaty, usually with and itch-burn sensation so in these pts I feel therapy does improve their quality of life. =========== From: Yelva@aol.com For maintenance after a course of oral ketoconazole, have him wash with ZNP bar, manufactured by Stiefel. It is my "secret weapon" for seb derm and T. Versicolor, works well even in AIDS patients, and is much better accepted for daily use than shampoos like Nizoral and Selsun.