A 10+ year old male presented with atrophic hyperpigmented, round, 3-4 mm macules on the neck, back, and chest, present for several months with mild diffuse xerosis. Several larger, oval plaques with scale were scattered around the neck. The patient denied pain and pruritus; topical steroids were ineffective. Mother has history of Sjogren’s syndrome and Scleroderma. The atrophic appearance of the eruption raised concern for lichen sclerosus or morphea and a biopsy was performed.

What is the cause of this eruption?

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Histologic sections show basket weave orthokeratosis overlying a normal thickness epidermis.  There is a sparse perivascular and patchy lichenoid lymphocytic infiltrate.  There is scattered pigment incontinence in the superficial dermis.  In the corneal layer, more numerous near the follicular ostia, there are numerous purpleish hyphal and yeast forms “spaghetti and meatballs” visible on standard H & E stain.


Malassezia yeast

Tinea Versicolor is a common yeast infection in young adults and teens, but can be seen in children and older adults as well. Lesions are more commonly hypopigmented but hyperpigmented variants are also well described. The hyperpigmented variant is a result of increase in the size and distribution of melanosomes in the basal layer, which is appreciated only on electron microscopy. Both forms show “spaghetti and meatball” yeast forms visible without special stain under the scope. These yeast forms live on your skin and help protect from other pathogens, but in this disease state, the yeast overgrow and cause the disorder in pigmentation. Tinea versicolor is not contagious but can be a tough condition to eradicate without recurrence. Selenium sulfide, antifungal creams, and oral antifungals are used, often in combination. Tinea Versicolor can appear differently in different skin tones, and sometimes can appear similar to vitiligo and even lichen sclerosis or morphea. Biopsy or KOH can differentiate these conditions.


The patient was started on econazole cream with great improvement.

By: Dr. Sapna Vaghani, MD; Dr. Kelli Hutchens, MD; and Dr. Betsy Wernli, MD