PREVALENCE AND CLINICAL FEATURES OF PITYRIASIS VERSICOLORAMONG STUDENTS IN TWO BOARDING SCHOOLS IN DENPASAR

Azhar Ramadan Nonci, Yulia Trisna Wijaya, IAK Utami Dewi, MadeSwastika Adiguna Department of

Dermatovenereology, Faculty of Medicine, Udayana University,Sanglah General Hospital, Denpasar, Indonesia

  

Background: Pityriasis versicolor (PV), is a common superficial fungalinfection of the skin. It is caused by Malassezia species andparticularly common in tropical and subtropical countries.Many factors are suspected to contribute to PV pathogenesis.Regarding these probable and possible risk factors, we feltthat boarding school is a unique population which can beaffected by this infection.

Objective:The aim of the present study was to determine the clinical andepidemiological profile of pityriasis versicolor in boardingschools in Denpasar.

Method:Total of 59 students of two boarding schools in Denpasar werescreened for PV. A 10% KOH examination of skin scrapping wasdone in all the screened students. PV was diagnosed instudents whose skin scrapings showed spores and hyphae. Aquestioner included, sex, age, disease duration, number ofoccupants/bedroom, pigmented changes and involved area isfilled for each screened student. The clinical andepidemiological data was noted.

Result:In the present study, 36% of all students were positive forPV, 86% were boys, and 14% were girls. PV was found to becommonest in the age group 11-15 years. The disease durationin 43% of students ranged 1-2 months. PV was highest in more

than 10 occupants per bed room (71%). In 57% screened studentsthe lesions were on the face and from all screened studentsthe lesions were hypopigmented macules.

Conclusion:Pityriasis versicolor was a high prevalence in boardingschools in Denpasar whereas environmental factors play a rolefor this disease.

Key words: prevalence, clinical features, pityriasis versicolor, boarding school

IntroductionPityriasis versicolor (PV) also called tinea versicolor is acommon chronic superficial fungal infection of the skin causedby Malassezia spp.1 The infection presents most commonly aspigmentation changes in the skin but also can be accompaniedwith pruritus.2 The etiologic agent Malassezia furfur is adimorphic, lipophilic fungus which is a common endogenoussaprophyte of normal skin. Under appropiate conditions, itconverts from the saprophytic yeast to the predominantlyparasitic mycelial morphology associated with clinicaldisease.3

Many predisposing factor have been proposed for thisdisease such as late teen and young adulthood age,4 tropicaland subtropical climate, immunosupresion,5 use of oralcontraceptive,6 hyperhidrosis,7 malnutrition,8 poor hygiene9 anda few other condition. This disease occurs worldwide withprevalence as high as 30-40% in populations in tropical area.Warm and humid environment is considered to be among theimportant precipitating factors.10 Indonesia is located in theequator belt with all-year temperatur averaging 300C andhumidity 70%.11 It is an infection seen usually in earlyadulthood and small children are not or rarely affected thoughfew studies have shown children to be affected by PV.12 Thelesions are usually seen on the trunk and upper extremities in

adults whereas in children it can also be the face, trunk orextremities.13

Regarding these probable and posible risk factors, wethought that overcrowded living condition boarding school is aunique population affected by this infection agent, therefore,we decided to determine the clinical and epidemiologicalprofile of this infection in them.

Material and MethodWe conducted this descriptive cross-sectional study in twoboarding schools in Denpasar city with a tropical orsubtropical climate on May 2013. Total of 59 students of twoboarding schools in Denpasar between 5-18 years, presentingwith pigmented changes were screened and examined for presenceof PV anywhere in body. Specimens were taken from the site oflesion of the screened students by scraping with scalpel bladefrom clinically suspected cases, mounted on glass slide,dissolved in 10% KOH solution. All specimen were delivered tomycology laboratory of dermatovenereology department ofUdayana university, Sanglah general hospital and examinedunder microscope by three experienced mycologicalmicroscopists. PV was diagnosed in students whose skinscrapings showed the characteristic clusters of spores withshort hyphae.

A questioner included, sex, age, disease duration, numberof occupants/bedroom, pigmented changes and involved area wasfilled for each screened student. The clinical andepidemiological data thus collected was noted and compiledusing MS Excel.

Result and DiscussionFrom 59 students in two boarding schools, 39 students who hadhypopigmented skin with scaly macules were screened. PVmanifests characteristic clinical lesions as slightly scalymacules that vary in colour from hypopigmented (white) tohyperpigmented (pink, tan to brown)1,2,14 The 10% KOH mountpositive in the students with hypopigmented macules of allstudents was 21 (36%) (Fig 1). The number of boys was 18 (86%)and girls 3 (14%) (Fig 2). Boys far out numbered girls (18versus 3). Similar boy preponderance was noted in some early

works.15 some other studies reported that the infection washigher in girls.16 We, however, believe that our finding in thisregard may not reflect true sex-wise prevalence of the diseasein the population. He et al. believe that the role of sex insusceptibility to disease and its development is stillunclear.17

Fig 1: Total number of students screneed andpositive with PV

The age range of the students was from 5-18 years. Thestudents were categorized into 3 age groups, while peakincidence of PV was in (11-15 years) groups (52%) (Fig 3). Thepeak of tinea versicolor is coincided with age. This possiblyis due to hormonal changes and increases in sebaceous glandactivity.18 Range for the duration of the disease was 1-5months. The high appearence of disease duration in 1-2 months(43%) (Fig 4). The distribution of PV according to number ofoccupants/bedroom, we devided into 3 groups. PV was highest inmore than 10 occupants per bed room (71%) (Fig 5). Boardingschool is a place where the humidity is very high due toovercrowding in one bedroom.

Table 1. Demographics and clinical characteristics among students in2 boarding schools in Denpasar

(n=21) %

Sex

Boys 18 86

Girls 3 14

Age 5-10 4 19

59 Total no. of students (5to 18 years)

39 Hypopigmented lesions

21 KOH positive

18 KOH negative

11-15 > 15

116

5229

Disease duration < 1 month 5 24

1-2 months 9 43

> 2 months

Number of occupants/bedroom 1-5 5-10 10-15

Involved area Face Neck Trunk Extremities

7

15

15

10442

33

52471

48191914

Denpasar is located in tropical or subtropicalclimate,with hot and humid conditions from May to September.There was an increase in the incidence of PV during the summerand monsoon season. Several reports showed that hot and humidconditions, and hygiene are susceptible factors for presentingpityriasis versicolor.17,19 Studies from india show an increasein the disease in the monsoon.12 Bouassida et al. also found anincrease in the incidence during summer months.4 However, Belecet al. believe that good or poor hygiene of the clothing had nosignificant influence on the prevalence of pityriasisversicolor.20

In our study, common sites of involment of this diseaseswas face (48%) (Fig 6). Other studies on pediatric populationconfirm that face is the most favored site of PV inchildren.4,21 All screened students presented with hypopigmentedlesions, multiple in member, well defined 2-4mm in size. Thisis not unexpected, because, in patients with dark skin, PV isthought to have a tendency to be hypopigmented.22

ConclusionIn conclusion, 36% students of two boarding schools inDenpasar were positive for pityriasis versicolor which is ahigh prevalence for this disease. Preferential faciallocalization in students age is characteristic of childhoodand tennagers. This was an expected outcome considering highlevel of physical activity, activity of sebaceous glands inthis age and lipophilicity of the causative fungus. PV shouldbe kept as a differential diagnosis in hypopigmented maculesespecially when on the face. The prevalence of PV increasedwith increase in the number of occupants per bedroom in theboarding schools. Having up to ten or more occupants in abedroom associated with poor hygiene, and overcrowded livingconditions and these facilitate the transmision of PV thatenvironment factors play a role for this disease. Further

studies will be necessary in order to explain therelationships of the environment factors and this disease.

References

1. El-Gothany ZMB. A review of pityriasis versicolor. J EgyptWom Dermatol Soc. 2004; 1(2): 36-43

2. Leeming JP, Notman FH, Holland KT. The distribution andecology of Malassezia furfur and cutaneous bacteria onhuman skin. J Appl Bacteriol 1989; 67: 47-52

3. Kundu RV & Garg A. Yeast Infections: Candidiasis, Tinea(Pityriasis) Versicolor, and Malassezia (Pityrosporum)Folliculitis. In: Goldsmith LA, Katz SI, Gilchrest BA,Paller AS, Leffell DJ, Wolf K. eds Fitzpatrick’sDermatology in general Medicine. 8th edn. New York:McGraw-Hill; 2012 p.2298-2311.

4. Bouassida S, Boudaya S, Ghorbel R. Pityriasis versicolorin children: Ann Dermatol Venereol 1998; 125: 581-584.

5. Gulec AT, Demirbilek M, Seckin D, Can F, Saray Y,Sarifakioglu E. Superficial fungal infections in 102renal transplant recipients: A case-control study. J AmAcad Dermatol 2003; 49: 187-192.

6. Borelli M, Jacobs PH, Nall L. Tinea versicolor:Epidemiologic, clinical, and therapeutic aspects. J Am AcadDermatol 1991; 25: 300-305.

7. Burke RC. Tinea vesicolor: Susceptibility factors andexperimental infection in human beings. J Invet Dermatol 1961;36: 389-402

8. Stein DH. Superficial fungal infection. Pediatr Clin North Am1983; 30: 545-561

9. Pontasch MJ, Kyanko ME, Brodel RT. Tinea versicolor ofthe face in black children in a temperate region. Cutis1989; 43: 81-4.

10. Sunenshine PJ, Schwartz RA. Tinea vesicolor. Int JDermatol 1998; 37: 648-655.

11. Krisanty RIA, Bramono K, Wisnu IM. Identification ofMalassezia species from pityriasis versicolor in Indonesiaand its relationship with clinical characteristic.Journal compilation 2008 Blackwell publishing Ltd Mycoses;52: 257-262.

12. Jena DK, Sengupta S, Dwari BC, Ram HK. Pityriasisversicolor in the pediatric group. Indian J Dermatol VenereolLeprol 2005; 71(4): 259-261.

13. Rijal A, Agrawal S, Bhattarai S. Prevalence andclinical features of pityriasis versicolor in children.Health Reinaissance NepJOL 2012; 10(2): 105-107

14. Crespo EV, Delgado FV. Malassezia species in skindiseases. Curr Opinion Infect Dis. 2002; 15: 133-142.

15. Selim MM, Kubec K. Pityriasis versicolor-epidemiological and therapeutical study. Mycoses 1989; 32:100-103.

16. Acosta Quintero ME. Cazorla Perfetti DJ. Clinical-epidemiological aspects of pityriasis versicolor (PV) ina fishing community of the semiarid region in Falconstate, Venezuela. Rev Iberoam Micol 2004; 21: 191-194.

17. He SM, Du WD, Yang S. The genetic epidemiology oftinea versicolor in China. Mycoses 2008; 51: 55-62

18. Mahmoudabadi AZ, Mossavi Z, Zarrin M. Pityriasisversicolor in Ahvasz, Iran. Jundishapur J Mirobiol 2009; 2(3):92-96

19. Asadi MA, Droudgar A, Houshyar H. Prevalence ofcutaneous mycoses among sanitary workers of citymunicipality of Kashan, 1998. Feyz, Kashan Uni Med Sci Heath Serv.1998; 9: 92-99.

20. Belec L, testa J, Bouree P. Pityriasis versicolor inthe Central african Republic: A randomized study of 144cases. J Med Vet Mycol. 1991; 29: 323-320.

21. Terragini L, Lasagni A, Oriani A, Gelmetti C.Pityriasis versicolor in the pediatric age. Pediatr Dermatol1991; 8: 9-12.

22. Maeda M, Makimura KC, Yamaguchi H, Pigmented changesof tinea versicolor in dark-skinned patients. Eur J Dermatol2001; 12: 160-164.