What is the treatment for Pityriasis versicolor?

Treatment of Pityriasis Versicolor

Topical antifungal medications are the first-line treatment for pityriasis versicolor, with selenium sulfide, ketoconazole, and terbinafine being the most effective options. 1

First-Line Treatment Options

Topical Treatments

1. Selenium Sulfide 2.5% Shampoo/Lotion

   • Apply to affected areas, lather with small amount of water
   • Leave on skin for 10 minutes, then rinse thoroughly
   • Use once daily for 7 days 2
   • Can be used weekly for maintenance therapy to prevent recurrence

2. Topical Azoles

   • Ketoconazole 2% (foam, cream, or shampoo)

     • Apply to affected areas twice daily for 2 weeks 3
     • Foam formulation shows good efficacy and patient satisfaction
     • Improvement in clinical features including scale, pigmentation changes, and pruritus

   • Clotrimazole cream

     • Apply twice daily for 2 weeks
     • Shows higher complete resolution rate (49.1%) at 2 weeks compared to oral fluconazole (30%) 4
     • Achieves 94.9% complete resolution after 4 weeks

3. Other Topical Options

   • Bifonazole solution
     • Apply daily for 2 weeks
     • As effective as selenium sulfide with lower relapse rate at 4 weeks 5
   • Terbinafine
   • Zinc pyrithione

Second-Line Treatment (For Extensive or Recalcitrant Cases)

Systemic Treatments

1. Fluconazole

   • Two doses of 300 mg with 2-week interval
   • 81.5% improvement rate after 1 month 6
   • Lower recurrence rate (6%) compared to topical treatments (18.2%) at 12 weeks 4
   • Preferred over ketoconazole due to better safety profile

2. Itraconazole

   • Alternative systemic option for extensive disease

Treatment Selection Algorithm

1. Limited Disease (< 25% body surface area)

   • Use topical treatments:
     • First choice: Ketoconazole 2% foam/cream twice daily for 2 weeks
     • Alternative: Selenium sulfide 2.5% daily for 7 days

2. Extensive Disease (≥ 25% body surface area)

   • Consider systemic treatment:
     • Fluconazole 300 mg, two doses with 2-week interval
     • Alternative: Itraconazole

3. Recurrent Disease

   • Consider maintenance therapy:
     • Selenium sulfide shampoo weekly
     • Or prophylactic oral antifungal therapy

Important Clinical Considerations

• Diagnosis: Confirm with KOH preparation showing "spaghetti and meatballs" appearance (hyphae and yeast forms)
• Treatment Expectations: Inform patients that color changes may persist for weeks to months after successful treatment
• Monitoring: Evaluate treatment response after 2-4 weeks
• Recurrence: Common due to Malassezia being part of normal skin flora; maintenance therapy may be necessary

Cautions and Pitfalls

• Oral ketoconazole should be avoided due to hepatotoxicity concerns 6
• Oral terbinafine is not effective for pityriasis versicolor 1
• Pigmentary changes may persist long after the fungus has been eradicated
• Treatment failure is often due to inadequate application of topical agents or premature discontinuation

Special Populations

• Pregnant women: Topical treatments preferred
• Children: Topical treatments preferred; adjust dosing of systemic treatments if necessary
• Immunocompromised patients: May require longer treatment duration and maintenance therapy