Tinea versicolor - Clinical Presentation And Treatment

Tinea versicolor is a common skin infection caused by the organism Pityrosporum orbiculare (also known as Malassezia furfur, Pityrosporum ovale, or Malassezia ovalis). The condition usually affects adolescents and young adults in tropical environments. The organism is a yeast that is a constituent of the normal skin flora.

Predisposing factors: A number of factors may trigger conversion to the mycelial or hyphal form that is associated with clinical disease, including

• hot and humid weather, 
• use of topical oils, 
• hyperhidrosis, and 
• immunosuppression. 

Clinical features: Tinea versicolor usually responds to medical therapy, but recurrence is common, and long-term preventative treatment may be necessary. Versicolor refers to the variety and changing shades of colors present in this condition. Lesions can be hypopigmented, light brown, or salmon-colored macules. A fine scale is often noted, especially after scraping. Individual lesions are typically small, but frequently coalesce to form larger lesions. Typically the lesions are limited to the outer skin, most commonly on the upper trunk and extremities, and are less common on the face and intertriginous areas. Most patients are asymptomatic; however, some may complain of mild pruritus.


The condition may occur in patients who are immunocompromised. It is most evident in the summer because the organism produces a substance that inhibits pigment transfer to keratinocytes, thus making infected skin more demarcated from uninfected, evenly pigmented skin.

Diagnosis: The diagnosis of tinea versicolor is made by microscopic examination of skin samples with 10% potassium hydroxide (KOH). Both hyphae and spores are evident in a pattern that is often described as “spaghetti and meatballs.”

The differential diagnosis includes

• seborrhea, 
• eczema, 
• pityriasis rosea, and 
• secondary syphilis. 

Seborrheic lesions are more frequently located on the central trunk, are more erythematous, and have thicker scales.
With eczema, patients usually have more scaling, pruritus, and involvement of the extremities.
Patients with pityriasis usually have a herald patch, more peripheral scale around border lesions, and confinement of lesions to the central trunk, and the lesions do not show hyphae on KOH prep. Secondary syphilis usually involves the hands and feet, and the lesions do not show hyphae on KOH
prep.

Treatment: Topical antifungal therapy given for 2 weeks is the treatment of choice for patients with mild and limited disease. Virtually any topical antiyeast preparation can be used with cure rates exceeding 70% to 80%.
Patients should be informed that the healing process continues after the treatment is complete. A return to normal pigmentation may take months after the completion of successful treatment. Oral medications are moreconvenient for patients with extensive disease and may also be more
effective in patients with recalcitrant infection. Most oral antifungal agents, with the exception of griseofulvin or terbinafine, may be used. Additionally, ketoconazole 2% shampoo in a single application or daily for 3 days may be considered as an option for treatment, especially with mild infections.