Tinea Versicolor

Tinea versicolor (pityriasis versicolor) is a superficial yeast infection caused by Malassezia species converting from commensal yeast to a mycelial form, giving hypopigmented, hyperpigmented or pink scaly macules. It is common in warm, humid climates and in adolescents and young adults.

• Risk factors: heat and humidity, sweating, oily skin, malnutrition, corticosteroid or immunosuppressive use, pregnancy, Cushing syndrome, HIV.
• Not contagious in the usual sense.

Well defined round to oval macules and patches, fine branny scale, on the upper trunk, neck, upper arms and sometimes face.

• Colours vary: pale in dark skin, tan or pink in light skin; mild or no itch.
• Wood lamp may show yellow gold fluorescence; scraping shows scale ("spaghetti and meatballs" on microscopy).
• Differential diagnosis: vitiligo, pityriasis alba, pityriasis rosea, secondary syphilis, seborrhoeic dermatitis, leprosy (tuberculoid or indeterminate), post inflammatory hypopigmentation, tinea corporis, confluent and reticulated papillomatosis.
• Complications: persistent dyspigmentation for months after cure, recurrence in 60 to 80 percent within two years, Malassezia folliculitis, cosmetic concern.

Clinical; KOH preparation of scale shows short hyphae and round yeast forms.

• Wood lamp examination.
• Culture is rarely needed.
• Slit skin smear for acid fast bacilli and sensation testing if leprosy is in the differential.
• Glucose and HIV test for extensive or recurrent disease.

Topical therapy is first line; oral therapy for extensive or recurrent disease.

• Supportive: explain that pigment change persists after cure and normalises over weeks to months, sun exposure makes macules more obvious, loose cotton clothing, wash after sweating.
• Pharmacological: selenium sulfide 2.5 percent lotion applied from neck to waist daily, left on for 10 minutes, for 7 to 10 days; ketoconazole 2 percent shampoo applied to the trunk and left for 5 minutes daily for 3 days; ketoconazole 2 percent cream or terbinafine 1 percent cream twice daily for 2 weeks; ciclopirox 1 percent cream. Oral itraconazole 200 mg daily for 5 to 7 days, or fluconazole 300 mg weekly for 2 to 4 weeks. Oral terbinafine does not work for this infection. Prophylaxis for recurrences: ketoconazole 2 percent shampoo or selenium sulfide once or twice monthly, or itraconazole 200 mg twice daily for one day each month for 6 months.
• Procedures: none.
• Special groups: pregnancy, topical selenium sulfide or ketoconazole shampoo only; children, ketoconazole shampoo or topical azole cream, avoid selenium sulfide on irritated skin; HIV, recurrences more common; liver disease, avoid oral azoles.
• Red flags: anaesthetic or hypopigmented patches with nerve thickening (leprosy), generalised rash with palm and sole involvement (syphilis), failure to respond to adequate therapy.
• Follow-up: review at 4 weeks; reassure about pigment; plan prophylaxis if recurrent.