Tinea Versicolor

(Pityriasis versicolor)


What tinea versicolor? — Tinea versicolor is a skin infection that causes areas of the skin to change color. The skin might have lighter patches, darker patches, or both light and dark patches.

Tinea versicolor is caused by a fungus. This fungus lives on people’s skin and does not cause problems normally. But in some people, the fungus can cause tinea versicolor. This happens more often in people who live where the weather is hot and humid.

Even though tinea versicolor is caused by fungus, it does not spread from one person to another. It is not “contagious.”

What are the symptoms of tinea versicolor? — Tinea versicolor often appears as lots of small spots of color that seem to run into each other and form large patches. The colors can vary from white to light brown, dark brown, gray-black or pinkish red. There can also be a mix of colors.

Tinea versicolor usually shows up on the back, chest, or upper arms. It can also happen on the face or in places where the skin rubs together, such as the armpit.

People often notice this problem more in the summer when affected areas of the skin stand out because they don’t get tan from the sun.

Is there a test for tinea versicolor? — Yes. After learning about your symptoms and doing an exam, your doctor or nurse might gently scrape the surface of your skin and look at the scrapings under a microscope. This procedure is usually not painful. If you have tinea versicolor, the doctor or nurse will see the fungus that causes the condition in the scrapings from your skin.

How is tinea versicolor treated? — Most mild cases of tinea versicolor only need a special “shampoo” or cream. The shampoo is used like a soap on the affected skin.

If your tinea versicolor covers a large part of your body, or if it doesn’t get better with the shampoo or cream, you might need medicine that comes in pills. Your doctor will decide if you need pills.

Even after you get treated, your skin might not go back to its normal color for several months. This does not mean the treatment didn’t work. It just takes time for the skin to heal.

First-line therapy — Topical antifungal medications, topical selenium sulfide, and topical zinc pyrithione are effective and well-tolerated first-line therapies for tinea versicolor.

Topical antifungals — Topical azole antifungals, topical terbinafine, and topical ciclopirox improve tinea versicolor via direct antifungal activity. Effective treatment regimens ranging from a few days to four weeks in length are reported in the literature.

Azole antifungals – Small randomized trials support the efficacy of various topical azole antifungals. In one randomized trial, ketoconazole 2% cream applied once daily for 11 to 22 days (mean 14 days) was superior to placebo (84 versus 22 percent achieved mycologic cure). A typical course of treatment with a topical azole antifungal is daily application for two weeks.

The shampoo formulation of ketoconazole appears to be effective with a shorter duration of therapy. The shampoo is applied to affected areas and is washed off after five minutes. In a randomized trial, a single application of ketoconazole 2% shampoo was compared with treatment on three consecutive days. Both regimens resulted in mycologic cure in approximately 80 percent of patients.

Terbinafine – Topical terbinafine 1% solution applied twice daily for one week has been proven effective in small randomized trials.

Ciclopirox – Topical ciclopirox olamine 1% cream was effective in two small randomized trials when applied twice daily for 14 days.

Selenium sulfide — Topical selenium sulfide exerts antifungal activity primarily through the promotion of shedding of the infected stratum corneum. In a randomized trial, application of selenium sulfide 2.5% lotion for 10 minutes for seven days was superior to placebo in achieving mycologic cure (81 versus 15 percent cured, respectively).

The shampoo formulation of selenium sulfide 2.5% is often prescribed in clinical practice. Patients apply the shampoo to the affected area daily for one week. The shampoo is rinsed off after 10 minutes.

A non-prescription selenium sulfide 1% shampoo is also available, but the efficacy of this product for the treatment of tinea versicolor has not been studied. Selenium sulfide 2.25% foam is a newer product that is applied twice daily without rinsing.

Zinc pyrithione — In a controlled trial that included 40 patients with tinea versicolor, zinc pyrithione 1% shampoo applied for five minutes per day for two weeks was more effective than placebo for the treatment of tinea versicolor. All patients treated with zinc pyrithione shampoo were successfully treated compared with none of the patients in the placebo group.

Severe or recalcitrant disease — Oral therapy is reserved for patients with tinea versicolor that is refractory to topical therapy or widespread disease that makes the application of topical drugs difficult. It is important to note that persistent dyspigmentation is not a good indicator of failure of topical therapy. 

Oral therapies — Oral azole antifungals such as itraconazole and fluconazole are effective for the treatment of tinea versicolor. In contrast to topical terbinafine, oral terbinafine is not effective. Similarly, griseofulvin cannot be used for this condition.

Systemic therapy is not used as a first-line treatment for limited tinea versicolor to minimize risk of adverse effects. Abnormalities in liver function tests and drug interactions can occur with systemic azole antifungals. 

Oral therapy is not typically used for the treatment of tinea versicolor in children.

Itraconazole — Itraconazole therapy for tinea versicolor in adults is usually given as 200 mg per day for five days. Multiple randomized trials have reported mycologic cure rates between 70 and 100 percent with 200 mg of itraconazole daily for seven days, and dose comparison studies have shown similar success with treatment durations of five days.

Data conflict on the efficacy of a single 400 mg dose of itraconazole. In a randomized, open-label trial, a single 400 mg dose was as effective as 200 mg daily for seven days. However, a low rate of response to a single 400 mg dose of itraconazole was reported in a trial that compared single-dose fluconazole and single-dose itraconazole.

Fluconazole — Fluconazole for tinea versicolor in adults is typically given as a 300 mg dose once weekly for two weeks. In a small, uncontrolled study, 300 mg once weekly for two weeks led to mycologic and clinical cure in 75 percent of patients with tinea versicolor. A dose-finding randomized trial also supports the efficacy of this regimen; 300 mg once weekly for up to two weeks resulted in mycologic cure in 87 percent of patients.

A single dose of fluconazole may be effective. In an uncontrolled study of 24 individuals with extensive or recurrent tinea versicolor treated with a single 400 mg dose of fluconazole, resolution of clinical disease occurred in 74 percent.

Other therapies — Additional topical and systemic therapies have been used for the treatment of tinea versicolor.

Topical agents – Whitfield ointment and sulfur-salicylic acid shampoo are effective for tinea versicolor, but may cause skin irritation in a minority of patients. Small uncontrolled studies suggest that propylene glycol and benzoyl peroxide may also improve tinea versicolor.

Oral ketoconazole – Although oral ketoconazole was effective for tinea versicolor in small randomized trials, life-threatening hepatotoxicity and adrenal insufficiency, along with multiple potential drug-drug interactions, have been reported with oral ketoconazole therapy, making it an unfavorable choice for the treatment of tinea versicolor. Although these adverse effects appear to be rare with the short duration of therapy used for tinea versicolor [44], knowledge of the potential for hepatotoxicity and the wide availability of safer oral antifungal agents led the European Medicines Agency to release a 2013 recommendation that marketing authorizations for oral ketoconazole be suspended throughout the European Union [45]. The US Food and Drug Administration (FDA) simultaneously removed its indication for use of the drug for dermatophyte and Candida infections based upon risks for hepatotoxicity, adrenal insufficiency, and drug-drug interactions. The FDA also recommended that oral ketoconazole should not be used as a first-line agent for any fungal infection. The indications for treatment of blastomycosis, coccidioidomycosis, histoplasmosis, chromomycosis, and paracoccidioidomycosis have been retained only for patients in whom other antifungal treatments have failed or are not tolerated.

In 2016, following an FDA safety review that found continued prescribing of oral ketoconazole for fungal skin and nail infections, the FDA released a drug safety communication warning healthcare professionals to avoid prescribing oral ketoconazole for fungal skin and nail infections. The risks of oral ketoconazole treatment outweigh the benefits.  

Treatment failure — Hypopigmentation and hyperpigmentation can persist for months following successful treatment of tinea versicolor, and may cause patients to assume incorrectly that treatment has failed. The presence of scale plus a positive potassium hydroxide (KOH) preparation is considered indicative of active infection.

Resistance to therapy, frequent recurrence, or widespread disease should prompt consideration of an immunodeficient state.

Can tinea versicolor be prevented? — If the tinea versicolor keeps coming back, there are shampoos or medicines that can help prevent it. Your doctor will work with you on the best treatment plan for your situation.

Dr. Carlo Oller
Board Certified Emergency Physician

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