II. Etiology

  1. Not a true dermatophyte (tinea) infections
  2. Caused by yeasts (genus Malassezia)
    1. Pityrosporum orbiculare
    2. Pityrosporum ovale
    3. Malassezia furfur (prior name for organisms above)

III. Signs

  1. Characteristics
    1. Macules with fine scale
    2. Hyperpigmented or hypopigmented Macules (or pink Plaques)
  2. Distribution
    1. Neck
    2. Trunk (chest and back)
    3. Proximal extremities

IV. Diagnosis

  1. Potassium Hydroxide (KOH)
    1. Scrape fine powdery scale with #15 blade
    2. Spaghetti (hyphae) and meatball (yeast) appearance
  2. Wood's Lamp (variably present)
    1. Irregular pale yellow fluorescence
    2. Fluorescence disappears with resolution

V. Differential Diagnosis

VI. Management

  1. Hypopigmentation resolves slowly after treatment
  2. Recurrent infections (recurrence rate is high)
    1. Consider repeat treatment prior to summer
    2. Frequently worn clothing may harbor fungus
      1. Consider discarding suspected clothing
      2. Consider boiling suspected clothing
  3. First Line: Topical Antifungal
    1. OTC versus prescription agents
      1. Both Selenium sulfide 1% (Selsun Blue) and Ketoconazole 1% (Nizoral A-D) are available OTC
      2. Best studied efficacy is with the higher concentration prescription items
        1. Efficacy of lower concentrations is unknown
    2. Selenium sulfide (Selsun, Exsel) 2.5% lotion
      1. Apply lather neck to knees
      2. Course
        1. Apply once daily for 7 days
        2. Wash off after 5-10 minutes
      3. Alternative regimen 1
        1. Apply three to five times per week for 2-4 weeks
        2. Wash off after 5-10 minutes
      4. Alternative regimen 2
        1. Apply once weekly for 4 weeks
        2. Wash off after 24 hours
    3. Zinc pyrithione
    4. Ketoconazole 2% cream
      1. Apply once daily for 14 days
    5. Terbinafine (Lamasil) topically
      1. May result in longer, sustained resolution
  4. Second line: Systemic Antifungal
    1. General
      1. Exercise to sweating after each dose
        1. May help distribute more medication to skin
      2. Avoid bathing for 12 hours after application
      3. Avoid oral Terbinafine due to low efficacy (possibly due to low skin concentrations)
    2. Fluconazole (preferred)
      1. 400 mg orally for one single dose OR
      2. 300 mg orally now and again in 2 weeks
    3. Itraconazole
      1. 400 mg orally daily for 3-7 days OR
      2. 200 mg twice daily for one day per month (to prevent recurrence)
    4. Ketoconazole
      1. Avoid due to hepatotoxicity risk (requires baseline and weekly Liver Function Test monitoring)
      2. Preveiously used at 400 mg orally for one single dose or 200 mg PO qd for 7 days

VII. References

  1. (2014) Presc Lett 21(7): 41
  2. Habif (1996) Clinical Dermatology, Mosby, p. 402-5
  3. Gilbert (2013) Sanford Antibiotic Guide
  4. Plensdorf (2017) Am Fam Physician 96(12): 797-804 [PubMed]
  5. Savin (1996) J Fam Pract 43(2):127-32 [PubMed]
  6. Zuber (2001) Postgrad Med 109(1):117-32 [PubMed]

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Related Studies

Ontology: Tinea Versicolor (C0040262)

Definition (NCI) A yeast infection usually manifested as a superficial skin infection. It may also present as a systemic infection in patients who are receiving total parenteral nutrition.
Definition (NCI) A skin condition characterized by hypopigmented, pink or tan, confetti-like, discrete and confluent scaly macules distributed on the chest, shoulders and upper back.
Definition (MSH) A common chronic, noninflammatory and usually symptomless disorder, characterized by the occurrence of multiple macular patches of all sizes and shapes, and varying in pigmentation from fawn-colored to brown. It is seen most frequently in hot, humid, tropical regions, and is caused by Pityrosporon orbiculare. (Dorland, 27th ed)
Concepts Disease or Syndrome (T047)
MSH D014010
ICD9 111.0
ICD10 B36.0
SnomedCT 154395007, 56454009
English Pityriasis Versicolor, Tinea Versicolor, tinea versicolor, tinea versicolor (diagnosis), Malassezia Furfur Infection, Tinea Versicolor [Disease/Finding], pityriasis versicolour, tinea flava, tinea versicolour, Pityriasis versicolour, Tinea versicolour, Pityriasis versicolor, Tinea versicolor, Tinea flava, Tinea versicolor due to Malassezia furfur, Tinea versicolor due to Pityrosporum furfur, PV - Pityriasis versicolor, TV - Tinea versicolor, Pityriasis versicolor (disorder), Malassezia furfur; infection, flava; tinea, infection; Malassezia furfur, pityriasis; versicolor, tinea; flava, tinea; versicolor, versicolor; pityriasis, versicolor; tinea, Infection by Malassezia furfur, Infection by Pityrosporum furfur, pityriasis versicolor
Italian Tinea versicolor, Pityriasis versicolor, Pitiriasi versicolor, Tigna versicolor
Dutch pityriasis versicolor, Malassezia furfur; infectie, flava; tinea, infectie; Malassezia furfur, pityriasis; versicolor, tinea; flava, tinea; versicolor, versicolor; pityriasis, versicolor; tinea, tinea versicolor, Pityriasis versicolor, Tinea versicolor
Portuguese Pitiríase versicolor, Tinha versocor, Pityriasis Versicolor, Tinha Versicolor
Spanish Pitiríasis versicolor, Pitiriasis versicolor, pitiriasis versicolor (trastorno), pitiriasis versicolor, tiña flava, tiña versicolor por Malassezia furfur, tiña versicolor por Pityrosporum furfur, tiña versicolor, Tiña versicolor, Pitiriasis Versicolor, Tiña Versicolor
Swedish Tinea versicolor
Japanese デンフウ, デンプウ, くろなまず, 癜風, でんぷう, でん風
Czech tinea versicolor, Pityriasis versicolor, Tinea versicolor
Finnish Savipuoli
Korean 잔비늘증(비강진)
Polish Łupież pstry, Grzybica pstra, Grzybica łupieżowa, Zakażenie Malassezia furfur
Hungarian tinea versicolor, pityriasis versicolor, Pityriasis versicolor
Norwegian Pityriasis versicolor, Tinea versicolor
French Pityriasis versicolor
German Pityriasis versicolor, Tinea versicolor