How do I treat tinea versicolor?

Treatment of Tinea Versicolor

For tinea versicolor, topical selenium sulfide 2.5% applied daily for 7 days is the first-line treatment, with oral antifungals reserved for extensive disease or treatment failures. 1

First-Line Topical Treatment Options

Selenium Sulfide 2.5%

• Apply to affected areas and lather with a small amount of water
• Allow to remain on skin for 10 minutes
• Rinse thoroughly
• Repeat once daily for 7 days 1
• Highly effective with minimal side effects
• Available over-the-counter

Ketoconazole 2% Shampoo

• Apply to affected areas, lather with water
• Leave on for 5 minutes before rinsing
• Use either as:
  • Single application regimen (1 day)
  • Daily application for 3 days 2
• Clinical response rates of 69% for single application and 73% for 3-day application 2
• Well-tolerated with minimal side effects

Second-Line Oral Treatment Options

For extensive disease, recurrent cases, or when topical therapy fails:

Fluconazole

• 300mg once weekly for 2 weeks
• Achieves 75% complete cure rate and 77.5% mycological cure rate by week 4 3
• No recurrences observed at 12-week follow-up
• Well-tolerated with minimal side effects

Ketoconazole

• 200mg twice weekly for 2 weeks
• Similar efficacy to fluconazole in comparative studies 4
• Maximum cure rate achieved at 8 weeks after treatment initiation

Treatment Considerations

Efficacy Assessment

• Clinical improvement may precede mycological cure
• Hypopigmentation may persist for weeks to months after successful treatment
• Wood's lamp examination is useful for confirming cure 4

Prevention of Recurrence

• Tinea versicolor has high recurrence rates
• For patients with frequent recurrences, consider prophylactic therapy:
  • Monthly topical selenium sulfide application
  • Or monthly oral antifungal during warm, humid months

Important Caveats

• Patients should be advised that skin color changes may persist for weeks to months after successful treatment
• Jewelry should be removed before applying topical treatments as they may damage metal 1
• Oral ketoconazole carries a higher risk of hepatotoxicity compared to other azoles and should be avoided if alternatives are available 5
• Wash hands thoroughly after applying topical treatments 1

Treatment Algorithm

1. For localized disease:

   • Start with selenium sulfide 2.5% daily for 7 days
   • Alternative: ketoconazole 2% shampoo for 1-3 days

2. For extensive disease or treatment failures:

   • Fluconazole 300mg once weekly for 2 weeks
   • Alternative: ketoconazole 200mg twice weekly for 2 weeks (if no liver concerns)

3. For recurrent cases:

   • Consider prophylactic therapy during warm months
   • Monthly application of topical agents or oral antifungal