Acral pityriasis versicolor-A rare clinical presentation

It was Eichstedt in 1846 who first noted the disease which is currently called as pityriasis versicolor (formerly tinea versicolor) [1]. Pityriasis versicolor is caused by various species of the genus Malassezia like M. Sympodialis, M. Furfur, M. Globosa, etc. Clinically patients present with hypopigmented or hyperpigmented macules which may be asymptomatic or with mild irritation. The sites of predilection include the upper trunk, upper arms, the neck and the abdomen. Less common sites include axilla, groins, popliteal fossae and genitalia [2]. Clinical presentation with lesions confined to the acral parts has rarely been described. The author reports a rare clinical variant of this disease where the lesions are restricted to the dorsal aspects of hands and the wrist.


INTRODUCTION
It was Eichstedt in 1846 who first noted the disease which is currently called as pityriasis versicolor (formerly tinea versicolor) [1].Pityriasis versicolor is caused by various species of the genus Malassezia like M. Sympodialis, M. Furfur, M. Globosa, etc. Clinically patients present with hypopigmented or hyperpigmented macules which may be asymptomatic or with mild irritation.The sites of predilection include the upper trunk, upper arms, the neck and the abdomen.Less common sites include axilla, groins, popliteal fossae and genitalia [2].Clinical presentation with lesions confined to the acral parts has rarely been described.The author reports a rare clinical variant of this disease where the lesions are restricted to the dorsal aspects of hands and the wrist.

CASE REPORT
A 40 year old male visited our dermatology department with a chief complaint of multiple asymptomatic hypo pigmented macules over d orsal aspects of both hands and wrist for the last one and a half months.There were no such lesions on any other parts of the body.He had no such history in the past.He denied any such complaints in his family members.On examination, there were multiple discrete scaly hypo pigmented macules present on the dorsal aspects of both hands and wrist (Figs 1a -c).The scaling of the macules became prominent on stretching the affected skin (positive Zireli's sign).The examination of hair, nail and mucous membrane was unremarkable.Potassium hydroxide (KOH) examination of the skin scrapings was done which showed multiple short hyphae and spores.He was prescribed topical Sertaconazole 2%

DISCUSSION
M. Furfur and the other related species of the genus Malassezia, the causative agents of Pityriasis versicolor, normally live on human skin in amounts which are undetectable on routine KOH examination of stratum corneum [3].In most cases, Pityriasis versicolor represents a shift in the relationship between the yeast and the human skin.The factors which lead to the development of pityriasis versicolor are multiple.However, the environmental factors and the individual host susceptibility are amongst the major ones.A high temperature and increased humidity in the tropical climates favor the disease.Oily skin, poor nutrition, immunodeficiency, pregnancy and corticosteroid use are the risk factors in the temperate climate [1,2].
Clinically, patients of pityriasis versicolor present with well defined discrete or confluent scaly macules, which may be hypo pigmented or hyper pigmented [4].The scaling of macules can be made prominent by stretching the affected skin and is called Zireli's sign [5].There are many morphological types of pityriasis versicolor reported in the literature which include hypochromic (commonest), hyperchromic, combination of hypochromic and hyperchromic, circinate, erythematous, atrophying, follicular, parasitic achromia (intense skin depigmentation occuring in melanodermic individuals), involving inguinocrural region and simulating erythrasma.Another type resembling pityriasis rubra pilaris has rarely been reported [5][6][7][8][9].Acral variant of the disease has been rarely reported.Ali Akbar, et al have reported an acral case of the pityriasis versicolor in which an 11 year old boy had reticulated hypo-pigmented macules on hands, feet, elbows and knees in a symmetrical distribution [6].However, in the present case the lesions are confined to the hands and the wrist which adds more rarity to the present communication and inspired the author to report the same.
The diagnosis of pityriasis versicolor is a clinical one without requiring any laboratory documentation.However, the diagnosis can be confirmed by potassium hydroxide (KOH) examination of the skin scrapings, which demonstrates the characteristic short, cigar-butt hyphae and spherical, thick-walled yeasts referred to as "spaghetti and meatballs" appearance [4].
The treatment of pityriasis versicolor includes both topical and systemic agents.Various topical preparations include topical azole antifungals, terbinafine 1% cream, 2.5% selenium sulphide in a detergent base, 50:50 propylene glycol in water, 20% sodium hyposulphite solution, nystatin, salicylic acid, etc.The oral antifungals effective in pityriasis versicolor include ketoconazole, fluconazole, itraconazole, etc. [1,2].In our case, the treatment given included topical sertaconazole 2% cream twice daily along with oral fluconazole 400 mg weekly for two weeks.The hypopigmentation took 2-3 months to recover after the institution of treatment.

CONSENT
The examination of the patient was conducted according to the Declaration of Helsinki principles.Written informed consent was obtained from the patient for publication of this article.

Figure 1 (
Figure 1 (a -c): Acral pityriasis versicolor: Multiple scaly hypopigmented macules on the dorsal aspects of the hands and the wristc