Tinea Versicolor

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

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

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

• Fungal culture is not useful

• 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

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