What is the treatment for tinea versicolor?

Treatment for Tinea Versicolor

Topical selenium sulfide is the first-line treatment for tinea versicolor, applied daily for 7 days to affected areas. 1

First-Line Treatment Options

Topical Treatments

• Selenium sulfide (1-2%):

  • Apply to affected areas, lather with water
  • Leave on skin for 10 minutes
  • Rinse thoroughly
  • Repeat once daily for 7 days 1

• Ketoconazole 2% shampoo:

  • Single application protocol: Apply to affected areas, leave on for 5 minutes, then rinse
  • Alternative protocol: Apply daily for 3 days
  • Both regimens show high efficacy (69-73% cure rate) 2

• Other effective topical agents:

  • Zinc pyrithione
  • Terbinafine cream
  • Clotrimazole 1% solution (applied twice daily for 2-4 weeks) 3

Second-Line Treatment (For Extensive or Recalcitrant Cases)

Oral Antifungal Therapy

• Fluconazole: 400mg as a single dose 4
• Itraconazole: 200mg daily for 5-7 days 4

Note: Oral terbinafine is not effective for tinea versicolor and should not be used 5

Treatment Selection Algorithm

1. For limited disease (small areas): Use topical therapy

   • First choice: Selenium sulfide 1-2% daily for 7 days 1
   • Alternative: Ketoconazole 2% shampoo (single application or 3-day regimen) 2

2. For extensive disease (large body surface area): Consider oral therapy

   • Fluconazole 400mg single dose OR
   • Itraconazole 200mg daily for 5-7 days 4

3. For recurrent cases:

   • Consider maintenance therapy with topical agents applied once weekly
   • Address predisposing factors (excessive sweating, occlusive clothing, humid environments)

Important Clinical Considerations

• Diagnosis: Tinea versicolor presents as hypo- or hyperpigmented macules with fine scale, most commonly on the trunk, neck, and upper arms

• Causative organism: Malassezia furfur (a lipophilic yeast that is part of normal skin flora)

• Common pitfalls:

  1. High recurrence rate: Inform patients that recurrence is common due to the presence of Malassezia in normal skin flora 5
  2. Delayed repigmentation: Explain to patients that color changes may persist for weeks to months after successful treatment
  3. Inadequate application: Ensure patients apply treatment to all affected areas, not just the most visible ones

• Follow-up: Clinical improvement should be evident within 1-2 weeks of treatment initiation, though pigmentary changes may persist longer

• Prevention: For patients with recurrent infections, consider prophylactic use of selenium sulfide or ketoconazole shampoo once weekly 5

While guidelines specific to tinea versicolor are limited, the evidence strongly supports topical selenium sulfide as first-line therapy, with topical azoles as effective alternatives and oral azoles reserved for extensive or resistant cases.