Tinea Versicolor (Pityriasis Versicolor)
BASICS
DESCRIPTION
- Superficial fungal infection presenting as hypopigmented, tan, brown, or salmon-colored macules.
- Well-demarcated, fine-scaled patches, often coalescing.
- Caused by Malassezia yeast (lipophilic, normal skin flora).
- Not a dermatophyte, not contagious, not related to poor hygiene.
- Synonyms: Pityriasis versicolor
EPIDEMIOLOGY
- Common worldwide, especially in tropical climates
- Peak incidence: adolescents and young adults
- Male = female
- Pediatric: post-puberty most common; facial lesions in children
- Rare in geriatric population
- Prevalence: Up to 50% in warm climates
ETIOLOGY & PATHOPHYSIOLOGY
- Caused by Malassezia species:
- P. orbiculare, M. furfur, M. ovalis
- Pathogenesis: yeast-to-mycelial transformation triggered by internal/external factors.
- Hypopigmentation: inhibition of melanin synthesis
- Hyperpigmentation: larger melanosomes
- Genetics: Possible predisposition
- Not contagious
RISK FACTORS
- Hot, humid weather
- Use of oily skin products
- Hyperhidrosis
- HIV / immunosuppression
- High cortisol states (Cushing’s, steroids)
- Pregnancy
- Malnutrition
- Oral contraceptive use
PREVENTION
- Avoid skin oils
- Consider prophylaxis in high-risk individuals before warm months or tanning season
- Not contagious, so isolation not needed
DIAGNOSIS
HISTORY
- Often asymptomatic
- Fine scaling macules, mildly pruritic
- Worsens in summer; more visible with sun tanning
- Common recurrence, especially in tropics
PHYSICAL EXAM
- Color: white, tan, salmon, or brown
- Distribution:
- Sebum-rich areas: chest, shoulders, back, neck, sometimes face/intertriginous zones
- In children: often facial involvement
- Macules may coalesce into patches
- Fine scaling enhanced by scraping (evoked scale)
DIFFERENTIAL DIAGNOSIS
- Pityriasis alba / rosea
- Vitiligo (no scaling)
- Seborrheic dermatitis (erythematous base, greasy scale)
- Nummular eczema
- Secondary syphilis
- Erythrasma
- Mycosis fungoides
DIAGNOSTIC TESTS
- KOH prep: hyphae + spores (“spaghetti and meatballs” pattern)
- Culture: not useful
- Routine labs: not required
TREATMENT
GENERAL MEASURES
- Treat visible lesions and prevent recurrence
- Pigment changes may take months to resolve
- Consider seasonal prophylaxis (e.g., spring)
TOPICAL ANTIFUNGALS – First Line for Limited Disease
| Agent | Frequency | Duration |
|---|---|---|
| Ketoconazole 2% shampoo | Leave on 5 min | 1–3 days |
| Ketoconazole 2% cream | BID | 2–4 weeks (contraindicated in pregnancy) |
| Selenium sulfide 2.25%/2.5% | Leave on 10–24 hrs | 1x/week x 4 weeks |
| Miconazole 2% | BID | 2–4 weeks |
| Ciclopirox olamine 1% | BID | 2 weeks |
| Terbinafine topical | BID | 2–4 weeks |
- Cure rates: 70–80%
- Pigment may take weeks to months to normalize
ORAL ANTIFUNGALS – Second Line / Extensive or Resistant Cases
| Agent | Dose | Duration | Notes |
|---|---|---|---|
| Itraconazole | 200 mg/day | 7 days | Cure rate >90% |
| Fluconazole (off-label) | 150–300 mg weekly | x2–4 weeks | |
| ⚠️ Oral ketoconazole | — | — | Not recommended (FDA warning – hepatotoxicity) |
REFERRAL INDICATIONS
- Treatment resistance
- Extensive involvement or immunocompromised host
- Consider dermatology referral
SURGICAL / ALTERNATIVE TREATMENTS
- Photodynamic therapy
- Narrow-band UVB (NB-UVB)
ONGOING CARE
PROPHYLAXIS
- Ketoconazole 2% shampoo once weekly during summer
- Itraconazole 400 mg monthly (in 2 divided doses)
FOLLOW-UP
- Pigment may take months to return
- Frequent recurrences → consider maintenance therapy
- Non-responders → re-evaluate for misdiagnosis or immunodeficiency
DIET
- No proven dietary prevention or cure
PATIENT EDUCATION
PROGNOSIS
- Recurrences are common, especially in hot climates
- Pigment variation may take months to normalize
- Lesions may persist for years if untreated
ICD-10 CODE
- B36.0 – Pityriasis versicolor
CLINICAL PEARLS
- Noncontagious superficial yeast infection
- Appears as scaly patches of varying color
- Becomes more obvious after tanning
- Recurs in summer months
- Pigment normalization is slow, not an indicator of treatment failure