What is the medical management of Tinea versicolor?

Medical Management of Tinea Versicolor

Topical ketoconazole 2% is the first-line treatment for tinea versicolor, applied once daily for two weeks to affected areas. 1

Diagnosis

• Tinea versicolor (pityriasis versicolor) is a common superficial fungal infection caused by Malassezia furfur (previously known as Pityrosporum orbiculare)
• Clinical presentation includes hypopigmented or hyperpigmented macules with fine scaling, often on trunk and upper arms
• Diagnosis can be confirmed with:
  • KOH preparation showing characteristic "spaghetti and meatballs" appearance
  • Wood's lamp examination showing yellowish fluorescence

Treatment Options

Topical Therapy (First-Line)

• Ketoconazole 2% cream: Apply once daily to affected areas for two weeks 1
• Ketoconazole 2% shampoo: Highly effective as either:
  • Single application (leave on for 5 minutes before rinsing)
  • Daily application for 3 days (leave on for 5 minutes before rinsing)
  • Both regimens show similar efficacy with clinical response rates of 69-73% 2

Oral Therapy (For Extensive Disease or Recurrent Cases)

When topical therapy is impractical due to large body surface area involvement or for recurrent cases:

1. Fluconazole:

   • 400 mg as a single dose, or
   • 150 mg once weekly for 2 weeks 3, 4

2. Itraconazole:

   • 200 mg daily for 5-7 days 3
   • 89% of patients achieve mycological cure with this regimen 5

3. Ketoconazole (oral):

   • 400 mg as a single dose repeated weekly for 2 weeks 4
   • Note: Oral ketoconazole carries higher risk of hepatotoxicity compared to newer azoles 6

Treatment Algorithm

1. Limited disease: Start with topical ketoconazole 2% cream once daily for two weeks
2. Extensive disease: Consider oral therapy with fluconazole or itraconazole
3. Recurrent disease: Consider prophylactic therapy with intermittent topical applications or periodic oral therapy

Important Clinical Considerations

• Hypopigmentation may persist for weeks to months after successful treatment
• Recurrence is common, especially in tropical climates and in patients with hyperhidrosis
• Wood's lamp examination is useful for monitoring treatment response 4
• There is often a lack of correlation between mycological cure and resolution of pigmentary changes 4

Common Pitfalls

• Treating only until clinical improvement without completing the full course, leading to recurrence
• Failure to recognize that pigmentary changes persist after mycological cure
• Not addressing predisposing factors (excessive sweating, occlusive clothing)
• Using terbinafine, which appears ineffective for tinea versicolor 3

Prevention of Recurrence

• Prophylactic use of ketoconazole 2% shampoo once monthly
• Avoidance of predisposing factors (excessive heat, humidity, occlusive clothing)
• For patients with frequent recurrences, consider periodic prophylactic oral therapy