Hyperpigmented patches.

TINEA VERSICOLOR

Tinea (pityriasis) versicolor (TV) is a superficial infection of the stratum corneum by the lipophilic fungus known as Malassezia furfur (formerly pityrosporum). The most common predisposing factor is excessive sweating but others include application of oils and systemic steroids.

A superficial infection by the fungus Malassezia of the trunk, usually in young people with oily skin.
Treatment is straightforward but maintenance is key as recurrences are common.
Wood's light illumination shows a characteristic golden-yellow fluorescence.
Oral ketoconazole should NOT be used as treatment for TV per the FDA--due to risk of severe hepatitis.

Clinical

The trunk is affected with brown, white, or pink, slightly scaly patches and very thin plaques. If no scale is appreciated, gentle scraping easily generates fine scale. Rarely, TV can affect other locations including the groin, sides of the neck and face. Atrophic lesions may occur. Folliculocentric TV has been reported.

Fluorescence

Malassezia fluoresces yellow-green with black (Wood's) light. In a study of 28 patients, 23 (82%) fluoresced positive with Wood's light. Positive KOH is the gold standard for diagnosis, but Wood's light is a rapid and inexpensive confirmatory tool.

Treatment

Initial Treatment

Ketoconazole 2% shampoo, lather scalp and trunk for 10 minutes daily for 7 days.
Itraconazole 200 mg/day for 5-7 days.
Fluconazole 300 mg once and repeat in one week.
Pramiconazole 200 mg/day for 2 days.
Topical antifungal, e.g., clotrimazole cream daily BID for 10 days.
Note: Terbinafine is of low efficacy and griseofulvin does not work.

It is very important to tell patients that the treatment will kill the fungus within days, but any color change will take weeks to months to return to normal. With regard to topical therapy, ketaconazole is the most studied and seemingly the most effective. Clotrimazole cream applied 2/day for 10 days is an alternative. Topical terbinafine is of lower efficacy. If it is to be used, it should be applied 2/day. Of the over-the-counter shampoos, zinc pyrithione seems to be the most effective.

With regard to oral anti fungal agents, itraconazole and fluconazole seem equally effective for the treatment of TV. For simplicity, fluconazole 300 mg po once and repeat in one week is recommended.

Maintenance

Recurrences are common so patients must use some sort of maintenance therapy for years, e.g., until their skin is less oily. This may be in the form of weekly ketoconazole 2% shampoo or topical clotrimazole cream. Some have used itraconazole 400 mg once a month for maintenance.

Additional Photos

Hypopigmented Patches

Many hypopigmented macules in a darker skinned patient.

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