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Pityrosporum Folliculitis Missed In Biopsy?

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Hi - I've been reading all the tons of helpful info on this site about pityrosporum folliculitis, and I'm more and more convinced that it's behind this rashy eruption mostly on my chest (and which is unlike any of the mild and generally well-managed face and body acne I've had much of my life). The thing is, my dermatologist DID actually do a punch biopsy because she thought PF could be a possibility, and it came back negative for yeast--apparently it just showed acne and inflammation. So she put me on doxycycline as well as a benzoyl peroxide cleanser and clindamyacin (i.e., antibacterial) lotion. Although it can wax and wane from day to day, generally it has definitely NOT gotten better in the 4 months since it first flared--and overall I think it's worse than before I started the doxy. Plus the topicals seem to really irritate it.

So I'm starting to wonder if it's possible that the punch biopsy missed it? She actually took the sample from a smaller, much less aggravated patch on my lower back (for the sake of a less conspicuous scar), but now I'm wondering if she should have taken it from my chest area after all. Is it possible the lower back area had too low a "concentration" of yeast to show on the biopsy? (Or maybe it's just "regular" acne, to which I'm certainly prone.) Would it be crazy to ask for another biopsy?

The derm wants to switch me to minocycline since the doxy clearly isn't working, but I'm skeptical. Minocycline has actually worked GREAT for me in the past for facial acne--but this latest chest issue actually started up while I was doing a 1-month course of mino to clear some mild cystic breakouts (which worked beautifully--during all this drama with my chest, my face has remained perfectly clear). I'm wondering if that last course of mino tipped the balance to trigger the PF flareup, and the more recent doxy is just making things worse...

Anyway, just wondering if others have experience/opinions on the biopsy question. In the meantime I think I may quit my current routine (orals and topicals) and try a week of Nizoral, Lotrimin, etc. If that shows any improvement at least I'll have something to take to my derm to discuss... Thanks in advance for any insights!

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It is definitely possible that a single biopsy might miss it because it totally depends on the sample the doc chose to assess. It is also possible to have bacterial folliculitis and fungal folliculitis occurring on you at the same time. I had all of these happen to me. The doc did a first biopsy (single sample) and found bacteria that he believed was a result of occluded sweat glands. I was put on oral doxycycline, clindamyacin lotion, sodium sulfacetamide lotion (all antibacterials). These did not work and seemed to make things worse. Probably because bacteria were killed off and allowed fungas to flourish more. A few months later we did a second biopsy (two samples) and they showed pityrosporum yeast. Over the last 8 months I completed two courses of oral fluconazole, one course of oral itraconazole, and washed entire torso daily with ketoconazole shampoo (all antifungals). These actions got me about 90-95% clear. The small amount of remaining issue (possibly bacterial) has just been eliminated in the past couple weeks with a cleanser called Hibiclen. You might want investigate and try this cleanser, it is good. Bottom line, you are definitely not crazy asking for a second biopsy. Hope you get your issue sorted out.

Edited by Torquemonster
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Torquemonster, thanks SO much for your quick and thorough reply! Hearing your experience really helped back up my gut feeling about what's going on with me. I'm going to switch OTC anti-fungals right away and make an appointment with the derm to discuss possibly prescription anti-fungals, with or without an additional biopsy. If she's resistant, I'll just find another derm. I've frankly been very un-impressed with her from the start. Last time I saw her, which was the 3rd or 4th time in the last few months, she didn't even seem to remember me. I would love to go back to a derm I saw regularly for several years but who no longer takes insurance...but might be worth paying out of pocket to work with someone I know will listen to me. (Sigh. Sad that it has to come to that.)

And Tom Busby, thanks too for that article (which I did manage to find), certainly helps make the argument that I should go by clinical results--i.e., antiobios are def not working for this, let's just see if anti-fungals do--regardless of biopsy/culture results. (Also interesting that the article said minocycline was the only tetracycline antibio shown effeftive on biofilms, since mino is the *only* one that has worked on my bacterial acne over the years. Food for thought.)

What a smart and helpful forum. Thanks again all.

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OP here again. Don't know if anyone will actually read this...but I just came back to say THANK YOU to everyone on this forum! After a week of using topical OTC anti-fungal products, I am 90% clear of the chest rash that lingered for 4+ months. Even the last few days of super hot, sticky weather here in NYC didn't seem to make it worse again. I went to see a new derm who agreed that I had pityrosporum folliculitis despite the original negative biopsy result; she's prescribed me a selenium sulfide foam to add into the mix. I will keep up the daily, multi-product regimen for a few more weeks just to be safe, but I'm confident I can soon taper down to just a few times a week for maintenance. And given all the information I learned on this site, I feel like I will be well armed to deal with any future outbreaks.

Thank you all SO much. This has been an amazing resource, and I feel so lucky to have found it relatively early in my ordeal.

Edited by Anonymouser
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OP here again. Don't know if anyone will actually read this...but I just came back to say THANK YOU to everyone on this forum!

Glad the condition is improving. Hope it stays that way.

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