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Key Features

Essentials of Diagnosis

  • Velvety, tan, pink, or white macules or white macules that do not tan with sun exposure

  • Fine scales that are not visible but are seen by scraping the lesion

  • Central upper trunk the most frequent site

  • Yeast and short hyphae observed on microscopic examination of scales

General Considerations

  • Mild, superficial Malassezia infection of the skin (usually of the upper trunk)

  • Patients often first notice that involved areas will not tan, causing hypopigmentation

  • High recurrence rate after treatment

Clinical Findings

Symptoms and Signs

  • Lesions are asymptomatic, with occasional itching

  • The lesions are velvety, tan, pink, white, or brown macules that vary from 4–5 mm in diameter to large confluent areas

  • The lesions initially do not look scaly, but scales may be readily obtained by scraping the area

  • Lesions may appear on the trunk, upper arms, neck, and groin

Differential Diagnosis

  • Seborrheic dermatitis

  • Pityriasis rosea

  • Postinflammatory pigmentary change (eg, acne, atopic dermatitis)

  • Secondary syphilis

  • Hansen disease (leprosy)

  • Vitiligo

    • Usually presents with periorificial lesions or lesions on the tips of the fingers

    • Characterized by total depigmentation, not just a lessening of pigmentation as with tinea versicolor

Diagnosis

Laboratory Tests

  • Large, blunt hyphae and thick-walled budding spores ("spaghetti and meatballs") are seen on KOH preparation

  • Fungal culture is not useful

Treatment

Medications

Topical treatments

  • Selenium sulfide lotion 2.5%

    • May be applied from neck to waist daily and left on for 5–15 min for 7 days

    • Repeat weekly for a month and then monthly for maintenance

  • Ketoconazole shampoo lathered on the chest and back and left on for 5 min may also be used weekly for treatment and to prevent recurrence

  • Imidazole creams, solutions, and lotions are quite effective for localized areas but are too expensive for use over large areas such as the chest and back

Systemic therapy

  • Fluconazole

    • Dosage: Two doses, 300 mg orally 14 days apart, is first-line treatment

    • Risk of hepatitis is minimal

  • Ketoconazole

    • 200 mg orally daily for 1 week or 400 mg as a single oral dose, with exercise to the point of sweating 30–60 minutes after ingestion, results in short-term cure of 90% of cases but is no longer recommended as first-line treatment because of the risk of drug-induced hepatitis

    • Patients should be instructed not to shower for 8 to 12 h after taking ketoconazole because it is delivered in sweat to the skin

    • An additional dose may be required in severe cases or humid climates

Therapeutic Procedures

  • Stress to the patient that the raised and scaly aspects of the rash ...

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