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For further information, see CMDT Part 6-14: Fungal Infections of the Skin

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

  • 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

    • Does not scale

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

  • Stress to the patient that the raised and scaly aspects of the rash are being treated; the alterations in pigmentation may take months to fade or fill in

  • Irritation and odor from therapeutic agents are common complaints from patients

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, 1% or 2%, lathered on the chest and back and left on for 5 min may 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

    • Additional doses may be required in severe cases or humid climates

Outcome

Complications

  • More protracted therapy with ketoconazole carries risk of drug-induced hepatitis

Prognosis

  • Relapses are common

  • Without maintenance therapy, recurrences will occur in over 80% of “cured” cases over the subsequent ...

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