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Tinea versicolor (pityriasis versicolor)
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Pityriasis (tinea) versicolor (PV), a superficial fungal infection of the skin, is caused by the lipophilic yeast species Malassezia , which are present in body areas rich in sebum, such as the face, back, upper trunk, etc. Malassezia fungi are a normal part of human commensal skin flora, and PV results when they are converted from the yeast phase to a mycelial phase, and then are able to infect the stratum corneum, producing the characteristic hypo- or hyperpigmented lesions.
Infection is associated with sebaceous gland activity; hence, infection is most often seen in adults and postpubescent adolescents, rarely in prepubescent children. An equal prevalence between the sexes has been noted. The risk factors are both endogenous and environmental, such as high temperature and humidity, malnutrition, the use of oral contraceptives, hyperhidrosis, genetic susceptibility, increased plasma cortisol levels, and immunodeficiency.
Initially, only two species of Malassezia (formerly known as Pityrosporum ) were described. Genetic research in the 1990s confirmed at least seven species of Malassezia , and more have since been discovered. Thus far, 14 species of the genus Malassezia have been identified, of which nine have been isolated from human skin.
Management Strategy
Topical treatment is the first-line therapy in most cases. Topical azoles formulated as gels, creams, solutions, or shampoos (ketoconazole, fluconazole, bifonazole, clotrimazole, miconazole, etc.) have demonstrated efficacy for PV. The allylamine terbinafine has several topical formulations (solution, cream, gel, or spray) that have been used effectively, as have formulations of the benzylamine butenafine . Topical ciclopirox provides both antifungal and anti-inflammatory activity against Malassezia .
Systemic antifungal therapies may be warranted in severe cases, or cases with widespread body involvement, patients with recurrent disease, or those who are immunocompromised. Patients may also prefer a short-duration oral therapy to frequent application of a topical agent.
Second-line therapy for cases refractive to topical therapy may be treated with oral antifungals. Itraconazole , fluconazole, and ketoconazole show high efficacy in the literature; however, it is now recommended by the US Food and Drug Administration and Health Canada that oral ketoconazole not be used for superficial fungal infections when less hepatotoxic alternatives are available. In contrast to topical terbinafine, oral terbinafine is not effective, and nor is griseofulvin.
Treatment does not vary with hyperpigmented versus hypopigmented disease. Although fungal organisms may be eradicated after 2–4 weeks of therapy, it may take significantly longer before the skin’s normal pigmentation is restored, particularly with hypopigmented lesions.
Relapse of PV is common owing to endogenous host factors: recurrence rates have been reported as high as 60%–90% 2 years after treatment. Both ketoconazole (a single 400 mg dose or 200 mg daily for 3 days once monthly) and itraconazole (a single 400 mg dose once monthly for 6 months) have been used in prophylactic regimens for PV, though oral ketoconazole is no longer recommended because of its potential for hepatotoxicity.
Specific Investigations
Malassezia organisms should be identified by skin scrapings for definitive diagnosis, and are easily identified with potassium hydroxide (KOH) microscopic examination, which reveals fungal hyphae in a typical ‘spaghetti and meatball’ pattern. Addition of a contrast stain such as 1% Chicago sky blue 6B and 8% KOH can assist microscopic visualization of Malassezia fungal species.
PV lesions fluoresce yellow/green or gold under Wood light; however, the examination is positive in only one-third of all PV cases, most likely when the causative organism is M. furfur .
Besides KOH microscopy and Wood light examination, dermoscopy is an adjunct diagnostic method for PV. White scaly patches on skin furrows with distinct demarcations are unique clinical features of PV that are visualized by dermoscopy.
First-Line Therapies
Pityriasis versicolor: a review of pharmacological treatment options
Gupta AK, Kogan N, Batra R. Exp Opin Pharmacother 2005; 6: 165–78.
This is a thorough summary of peer-reviewed studies of topical and oral therapies in the treatment of tinea versicolor until 2005. Azole topical agents have shown good mycological cure, clinical cure, and complete cure in many double-blind randomized clinical trials, as have the non-specific topical agents (zinc pyrithione shampoo, selenium sulfide, etc.) and terbinafine.
Terbinafine 1% cream and ketoconazole 2% cream in the treatment of pityriasis versicolor: a randomized comparative clinical trial
Rad F, Nik-Khoo B, Yaghmaee R, et al. Pak J Med Sci 2014; 30: 1273–6.
A randomized, single-blind trial, with terbinafine 1% cream or ketoconazole 2% cream applied twice daily for 2 weeks. Cure rates (negative KOH microscopy with clinical cure) at 2 weeks (terbinafine: 72.1%; ketoconazole: 64.3%) and 8 weeks (terbinafine: 70.8%; ketoconazole: 61.9%) were not significantly different between treatments.
Can pityriasis versicolor be treated with 2% ketoconazole foam?
Cantrell WC, Elewski BE. J Drugs Dermatol 2014; 13: 855–9.
Eleven patients in this pilot study applied ketoconazole 2% foam twice daily for 2 weeks. Clinical improvement was observed over 4 weeks and seven patients showed negative KOH microscopy.
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