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InFocus

Feline Malassezia dermatitis and otitis: are we missing it?

Unless one specifically looks for them, Malassezia organisms can be missed, which results in difficult to manage primary diseases and ongoing client dissatisfaction

Malassezia dermatitis (also referred to as Malasse­zia overgrowth syndrome) and otitis may be more prevalent than recognised. Malassezia infections are common in allergic dogs but there is little information in cats. A small number of these yeast organisms are found on healthy cats; however, a breakdown in the epidermal barrier and changes in the microbiome lead to an over­growth of the organism. Malassezia pachydermatis is the organism most associated with infections, but other species such as M. sympodialis, M. nana, M. furfur and M. globosa (Bond et al., 1996, 1997; Crespo et al., 1999, 2000) have been implicated in infections.

Risk factors

The factors that contribute to the shift in Malassezia popu­lation in cats are:

Genetics

Some breeds may have a higher carriage rate of Malassezia on the skin and ears. Healthy Devon Rex cats were shown to have higher carriage of Malassezia on the skin which may be one of the reasons why they are predisposed to seborrhoeic dermatitis (Bond et al., 2008). A breed predis­position is recognised in Sphynx cats and in both Devon and Cornish Rex cats (Ahman et al., 2007; Ahman and Berg­strom, 2009).

Allergies

Sensitivities to environmental and dietary allergens have been associated with an overgrowth of Malassezia (Ordeix et al., 2007), but it is important to note that not all allergic cats develop Malassezia dermatitis.

Immune dysregulation and systemic disease

In one report Malassezia was isolated more frequently from retroviral positive cats compared to those that were neg­ative (Sierra et al., 2000), which suggests that overgrowth may be linked to an underlying immune dysregulation.

Immunosuppression associated with anti-inflammatory drugs, like glucocorticoids and immunomodulators such as ciclosporin and chlorambucil, could be a contributing factor to population changes during the management of the primary diseases.

In some cases, Malassezia overgrowth may indi­cate systemic disease (eg inflammatory bowel disease, hyperadrenocorticism, diabetes mellitus, hyperthyroidism) and/or paraneoplastic syndromes (eg exfoliative derma­titis associated with a thymoma, paraneoplastic alopecia, systemic neoplasia) (Forster-Van Hijfte et al., 1997; Godfrey, 1998; Perrins et al., 2007). If large numbers of organisms are found during a case work-up, a detailed history, clinical signs, laboratory tests and imaging modalities relating to the underlying disease are indicated to reach a diagnosis and prognosis. Note that some of these conditions have a poor to guarded prognosis.

Clinical signs

The clinical signs are variable and may well depend on the underlying condition, and there is no particular distribution pattern. Not all cases of Malassezia infections are pruritic in the initial stages, but can become so with time. The lesions include dry (Figure 1) or greasy scale, erythema, follicular casts, brown exudate (Figure 2), alopecia and hyperpigmentation.

Cats with Malassezia otitis have brown to black cerumi­nous exudate in the ear canals (Figure 3), stenosis, ery­thema and self-inflicted lesions on the preauricular skin.

Accumulation of brown to black exudate on the claw folds or in the claws are seen in some cases (Figure 4) as well as on the feet (Figure 5). Some of these cats are presented with a history of claw or feet biting and licking. Predisposed breeds such as the Devon Rex present with seborrhoeic dermatitis.

FIGURE (1) This young cat presented with generalised large dry scales which had been present since it was a kitten. It was hand reared and a poor innate immunity was suspected as the trigger for colonisation with Malassezia
FIGURE (2) Erythema, alopecia and fine brown exudate are common clinical signs in feline patients with Malassezia infection, here found on the axilla and ventral aspect of a Devon Rex cat
FIGURE (3) Ceruminous otitis externa is associated with Malassezia in cats
FIGURE (4) Thick brown exudate can be found on the claw beds in cats with Malassezia
FIGURE (5) Brown exudate on the plantar aspect of a Devon Rex cat with pedal pruritus

Diagnosis

The diagnosis is based on history, clinical signs, demonstra­tion of the organisms on cytology and response to anti­fungal treatment. Culture for Malassezia on the skin is not generally done; however, their presence is often reported on ear swabs.

FIGURE (6) Tape strip cytology is an effective way of identifying Malassezia organisms in cats

Cytology

Malassezia organisms are footprint to ovoid in shape, and the quickest way to identify them is using tape strips on the skin (Figure 6) and/or swabs from ears, stained in Diff Quik.

Response to treatment

To ascertain the role of Malassezia in the severity of lesions and/or their contribution in increasing the level of pruritus, it is best to treat. A reduction in pruritus or lesion scores supports their role in the disease.

Culture

M. pachydermatis is readily cultured using standard mycolog­ical techniques as it is non-lipid dependent, but other Malas­sezia spp. require a lipid-enriched culture medium to grow on.

Histopathology

Skin biopsies may show large numbers of Malassezia in the stratum corneum. The presence of very large numbers of organisms in the absence of an allergy could be suggestive of immune dysregulation and/or systemic disease.

Treatment

Treatment should be individualised on a case-by-case basis. It will depend on the extent and severity of the lesions, the underlying disease, owner compliance and the temperament of the cat.

Topical treatment is most useful for cats with otitis. Ear preparations containing miconazole, clotrimazole and nystatin are licensed for cats in the UK. Shampoo treatment using miconazole/chlorhexidine shampoo is useful (Figure 7), but cats are not the easiest animals to bathe. Mousse products containing climbazole/chlorhexidine may be useful for some individuals.

FIGURE (7A) This Devon Rex cat with eosinophilic dermatitis and concurrent Malassezia dermatitis associated with inflammatory bowel disease (IBD)…
FIGURE (7B) … was treated with topical 2% chlorhexidine/2% miconazole shampoo and ongoing management of IBD with ciclosporin

Systemic antifungals are indicated if topical treatment is ineffective or impractical. Itraconazole at 5mg/kg once daily orally, as a pulse treatment of seven days on and seven days off, can be used. A marked improvement in clinical signs with a reduction in pruritus and inflammation has been demonstrated in studies (Bensignor, 2010; Ahman et al., 2007). Generally, two cycles are sufficient to assess the response to treatment.

Summary

Given that the cutaneous microbiome can be affected by a wide range of skin diseases, overgrowth of Malassezia can occur with any of them. Unless one specifically looks for their presence on the skin in cats with pruritus and/or dermatitis, they can be missed, which results in difficult to manage primary diseases and ongoing client dissatisfac­tion. Malassezia dermatitis and otitis are easy to diagnose and treat, resulting in better and more successful manage­ment of primary diseases.

References

Ahman, S. E. and Bergstrom, K. E.

2009

Cutaneous carriage of Malassezia species in healthy cats and seborrheic Sphynx cats and a comparison to carriage in Devon Rex cats. Journal of Feline Medicine and Surgery, 11, 970-976

Ahman, S., Perrins, N. and Bond, R.

2007

Treatment of Malassezia pachydermatis‐associated seborrhoeic dermatitis in Devon Rex cats with itraconazole – a pilot study. Veterinary Dermatology, 18, 171-174

Bensignor, E.

2010

Treatment of Malassezia overgrowth with itraconazole in 15 cats. Veterinary Record, 167, 1011-1012

Bond, R., Anthony, R. M., Dodd, M. and Lloyd, D. H.

1996

Isolation of Malassezia sympodialis from feline skin. Journal of Medical and Veterinary Mycology, 34, 145-147

Bond, R., Howell, S. A., Haywood, P. J., Lloyd, D. H.

1997

Isolation of Malassezia sympodialis and Malassezia globosa from healthy pet cats. Veterinary Record, 141, 200-201

Bond, R., Stevens, K., Perrins, N. and Ahman, S.

2008

Carriage of Malassezia spp. yeasts in Cornish Rex, Devon Rex and Domestic short-haired cats: a cross-sectional survey. Veterinary Dermatology, 19, 299-304

Crespo, M. J., Abarca, M. L. and Cabanes, F. J.

1999

Isolation of M. furfur from a cat. Journal of Clinical Microbiology, 37, 1573-1574

Crespo, M. J., Abarca, M. L. and Cabanes, F. J.

2000

Otitis externa associated with M. sympodialis in two cats. Journal of Clinical Microbiology, 38, 1263-1266

Forster-Van Hijfte, M. A., Curtis, C. F. and White, R. N.

1997

Resolution of exfoliative dermatitis and M. pachydermatis overgrowth in a cat after surgical thymoma resection. Journal of Small Animal Practice 1997, 38, 451-454

Godfrey, D. R.

1998

A case of feline paraneoplastic alopecia with secondary Malassezia-associated dermatitis. Journal of Small Animal Practice, 39, 394-396

Ordeix, L., Galeotti, F., Scarampella, F., Dedola, C., Bardagí, M., Romano, E. and Fondati, A.

2007

Malassezia spp. overgrowth in allergic cats. Veterinary Dermatology, 18, 316-323

Perrins, N., Gaudiano, F. and Bond, R.

2007

Carriage of Malassezia spp. yeasts in cats with diabetes mellitus, hyperthyroidism and neoplasia. Medical mycology, 45, 541-546

Sierra, P., Guillot, J., Jacob, H., Bussiéras, S. and Chermette, R.

2000

Fungal flora on cutaneous and mucosal surfaces of cats infected with feline immunodeficiency virus or feline leukemia virus. American journal of veterinary research, 61, 158-161

Anita Patel

Anita Patel, BVM, DVD, FRCVS, is an RCVS Recognised Specialist in Veterinary Dermatology who runs a referral practice in the South East of England. She has co-authored a text book, has publications in journals and lectures in dermatology all over the world.


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