Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 6-14: Fungal Infections of the Skin + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ Large, blunt hyphae and thick-walled budding spores ("spaghetti and meatballs") are seen on KOH preparation Fungal culture is not useful + Treatment Download Section PDF Listen +++ ++ 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 ++ See Table 6–2 +++ 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 Download Section PDF Listen +++ +++ 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 2 years +++ When to Refer ++ There is a question about the diagnosis Recommended therapy is ineffective Specialized treatment is necessary + References Download Section PDF Listen +++ + +Hudson A et al. JAMA patient page. Tinea versicolor. JAMA. 2018 Oct 2;320(13):1396. [PubMed: 30285180] + +Rosen T. Mycological considerations in the topical treatment of superficial fungal infections. J Drugs Dermatol. 2016 Feb;15(2 Suppl):s49–55. [PubMed: 26885799]