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Tinea Versicolor
Elisabeth L. Backer, MD
image BASICS
DESCRIPTION
  • Rash due to a common superficial mycosis with a variety of colors and changing shades of color, predominantly present on trunk and proximal upper extremities; macules are usually hypopigmented, light brown, or salmon-colored; fine scale is often apparent. It is not a dermatophyte infection.
  • System(s) affected: skin/exocrine
  • Synonym(s): pityriasis versicolor
EPIDEMIOLOGY
Incidence
  • Common, occurs worldwide, especially in tropical climates, where prevalence can reach 50%
  • Predominant age: teenagers and young adults
  • Predominant sex: male = female
Pediatric Considerations
Usually occurs after puberty (except in tropical areas); facial lesions are more common in children.
Geriatric Considerations
Not common in the geriatric population
ETIOLOGY AND PATHOPHYSIOLOGY
Inhibition of pigment synthesis in epidermal melanocytes, leading to hypomelanosis; in the hyperpigmented type, the melanosomes are large and heavily melanized (1).
  • Saprophytic yeast: Pityrosporum orbiculare (also known as P. ovale, Malassezia furfur, or M. ovalis), which is a known colonizer of all humans
  • Development of clinical disease associated with transformation of Malassezia from yeast cells to pathogenic mycelial form due to host and/or external factors.
  • Not linked to poor hygiene
Genetics
Genetic predisposition may exist.
RISK FACTORS
  • Hot, humid weather
  • Use of topical skin oils
  • Hyperhidrosis
  • HIV infection/immunosuppression
  • High cortisol levels (Cushing, prolonged steroid administration)
  • Pregnancy
  • Malnutrition
  • Oral contraceptives
GENERAL PREVENTION
  • Recheck and treat again each spring prior to tanning season.
  • Avoid skin oils.
image DIAGNOSIS
PHYSICAL EXAM
  • Versicolor refers to the variety and changing shades of colors. Color variations can exist between individuals and also between lesions.
  • Sun-exposed areas: Lesions are usually white/hypopigmented.
  • Covered areas: Lesions are often brown or salmon-colored.
  • Distribution (sebum-rich areas): chest, shoulders, back (also face and intertriginous areas)
    • Face is more likely to be involved in children.
  • Appearance: small individual macules that frequently coalesce
  • Scale: fine, more visible with scraping
DIFFERENTIAL DIAGNOSIS
Other skin diseases with discolored macules and plaques, including the following:
  • Pityriasis alba/rosea (“Christmas tree-like” distribution visible in P. rosea)
  • Vitiligo (presents without scaling)
  • Seborrheic dermatitis (more erythematous; thicker scale)
  • Nummular eczema
  • Secondary syphilis
  • Erythrasma
  • Mycosis fungoides
DIAGNOSTIC TESTS & INTERPRETATION
Wood lamp: yellow to yellow-green fluorescence or pigment changes
Initial Tests (lab, imaging)
  • Direct microscopy of scales with 10% potassium hydroxide (KOH) preparation to visualize hyphae and spores (“spaghetti and meatballs” pattern)
  • Routine lab tests are usually not necessary.
  • Fungal culture is not useful.
Test Interpretation
  • Short, stubby, or Y-shaped hyphae
  • Small, round spores in clusters on hyphae
image TREATMENT
GENERAL MEASURES
  • Apply prescribed topical medications to affected skin with cotton balls.
  • Pigmentation may take months to fade or fill in.
  • Repeat treatment each spring prior to sun exposure; some may require repeated treatment during the summer as prophylaxis.
  • Patients who fail topical treatment can be treated with an oral/systemic medication.
MEDICATION
Topical antifungal therapy is the treatment of choice in limited disease. Evidence is generally of poor quality, but data suggest that longer durations of treatment and higher concentrations of active agents produce greater cure rates (2)[A].
First Line
  • Ketoconazole 2% shampoo applied to damp skin and left on for 5 minutes for 1 to 3 days or
  • Selenium sulfide shampoo 2.5% (Selsun):
    • Allowed to dry for 10 minutes prior to showering: daily for 1 week or
    • Allowed to remain on body for 12 to 24 hours prior to showering: once a week for 4 weeks or
  • P.1043

  • Clotrimazole 1% topical (Lotrimin) BID for 2 to 4 weeks or
  • Miconazole 2% (Micatin, Monistat) BID for 2 to 4 weeks or
  • Ketoconazole 2% (Nizoral) cream BID for 2 to 4 weeks or
  • Terbinafine (Lamisil) 1% solution BID for 1 week or
  • Terbinafine (Lamisil Derm Gel) once daily for 1 week
  • Cure rates of topical antiyeast preparations typically 70-80%; healing continues after active treatment. Resumption of even pigmentation may take months.
  • Contraindications: Ketoconazole is contraindicated in pregnancy.
  • Newer preparations: 2.25% selenium sulfide foam; ketoconazole 2% gel
Second Line
  • Use for extensive disease or nonresponders
  • Oral fluconazole 300 mg once weekly for 2 weeks (3)[A]
  • Itraconazole 200 mg/day PO for 1 week; cure rate >90% (3)[A]
  • Oral ketoconazole is no longer recommended by FDA due to risks of hepatotoxicity, adrenal insufficiency, and drug-drug interactions.
  • Oral terbinafine or griseofulvin is not effective.
  • Pramiconazole has been studied but is not yet available for clinical use.
ISSUES FOR REFERRAL
  • If resistant to treatment
  • If extensive disease occurs in immunocompromised host
image ONGOING CARE
  • Ketoconazole 2% or selenium sulfide 2.5% shampoo can be used weekly for maintenance or monthly for prophylaxis.
  • Itraconazole 400 mg once monthly during the warmer months of the year can also reduce recurrences.
FOLLOW-UP RECOMMENDATIONS
Warn patients that whiteness will remain for several months after treatment.
Patient Monitoring
  • Recheck and treat again each spring prior to tanning season.
  • Failure to respond should prompt reassessment or dermatology referral.
  • Resistance to treatment, frequent recurrences, or widespread disease may point to immunodeficiency.
PATIENT EDUCATION
For patient education materials favorably reviewed on this topic, contact American Academy of Dermatology, 930 N. Meacham Road, P.O. Box 4014, Schaumberg, IL 60168-4014; (708) 330-0230.
PROGNOSIS
  • Duration of lesions months/years
  • Recurs almost routinely because this yeast is a known human colonizer
  • Pigmentary changes may take months to resolve.
REFERENCES
1. Morishita N, Sei Y. Microreview of pityriasis versicolor and Malassezia species. Mycopathologia. 2006;162(6):373-376.
2. Hu SW, Bigby M. Pityriasis versicolor: a systematic review of interventions. Arch Dermatol. 2010;146(10):1132-1140.
3. Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg. 2014;18(2):79-90.
Additional Reading
&NA;
  • Bhogal CS, Singal A, Baruah MC. Comparative efficacy of ketoconazole and fluconazole in the treatment of pityriasis versicolor: a one year follow-up study. J Dermatol. 2001;28(10):535-539.
  • Faergemann J, Todd G, Pather S, et al. A doubleblind, randomized, placebo-controlled, dose-finding study of oral pramiconazole in the treatment of pityriasis versicolor. J Am Acad Dermatol. 2009;61(6):971-976.
  • Güleç AT, Demirbilek M, Seçkin D, et al. Superficial fungal infections in 102 renal transplant recipients: a case-control study. J Am Acad Dermatol. 2003;49(2):187-192.
  • Gupta AK, Batra R, Bluhm R, et al. Pityriasis versicolor. Dermatol Clin. 2003;21(3):413-429.
  • Köse O, Bülent Taştan H, Riza Gür A, et al. Comparison of a single 400 mg dose versus a 7-day 200 mg daily dose of itraconazole in the treatment of tinea versicolor. J Dermatolog Treat. 2002;13(2):77-79.
Codes
&NA;
ICD10
B36.0 Pityriasis versicolor
Clinical Pearls
&NA;
  • Noncontagious macules of varying colors, with fine scale
  • Recurrence in summer months
  • More apparent after tanning. Skin areas with fungal infection do not tan; thus, hypopigmented areas become more visible.
  • Warn patients that whiteness will remain for several months after treatment.