BACKGROUND Malassezia folliculitis commonly has been treated with oral antifungal medications. However, it has many therapeutic weaknesses such as infection relapse, drug resistance, or adverse effects like hepatotoxicity and gastrointestinal discomfort. Hence, there remains an ongoing need for alternative treatments for recalcitrant Malassezia folliculitis. Recently, many dermatologists suggest photodynamic therapy (PDT) as an alternative therapeutic option for its antimicrobial effect. OBJECTIVE To investigate the efficacy of methyl 5-aminolevulinic acid (MAL)-PDT for the treatment of recalcitrant Malassezia folliculitis. METHODS Six Korean patients aged 23-47 years with recalcitrant Malassezia folliculitis were enrolled in this study. The patients enrolled in this study either refused oral medication or were unable to take oral antifungal agents due to hepatotoxicity concerns. Thus, we offered these patients MAL-PDT as an alternative treatment option. For all patients, photographs of the lesion(s) were taken prior to initiating treatment. MAL cream (Metvix, Galderma, France) was applied to each lesion (located on the patients' trunks) and covered with an adhesive occlusive dressing polyurethane film (Tegaderm, 3M Healthcare, St. Paul, MN). After 3 hours, the cream was wiped off and illumination was performed immediately thereafter with non-coherent red light using light-emitting diodes (Aktilite lamp, PhotoCure, Oslo, Norway, average wavelength 630 nm, light dose 37 J/cm(2)). Illumination was performed for 7.5 minutes. Patients underwent totally three sessions of MAL-PDT at 2-week intervals. One month after the last PDT treatment, patients returned to the hospital and lesions were photographed. RESULTS After three sessions of MAL-PDT, inflammatory lesions had decreased and improved obviously in four patients, had improved slightly in one patient, and had not improved in one patient. CONCLUSIONS MAL-PDT may be an effective treatment option for patients with recalcitrant Malassezia folliculitis. However, the data on MAL-PDT are still limited, and additional controlled trials including multiple patients will be necessary to verify the results of this pilot study.