What is the treatment for Tinea versicolor?

Treatment of Tinea Versicolor

Topical antifungal therapy is the first-line treatment for tinea versicolor due to its favorable safety profile, fewer adverse events, and lower cost compared to systemic treatment. 1

Diagnosis

• Tinea versicolor (pityriasis versicolor) is a common superficial fungal infection caused by Malassezia species (notably M. globosa, M. furfur, and M. sympodialis)
• Characterized by scaly hypopigmented or hyperpigmented macules/patches, primarily on upper trunk, neck, and upper arms
• Diagnosis is usually based on characteristic clinical features
• If necessary, potassium hydroxide (KOH) preparation can confirm diagnosis by revealing short, stubby hyphae intermixed with clusters of spores

Treatment Algorithm

First-Line Treatment: Topical Antifungal Therapy

1. Topical azole antifungals:

   • Ketoconazole 2% shampoo (apply to affected areas, leave on for 5 minutes, then rinse off)
   • Clotrimazole 1% solution applied twice daily for 2-4 weeks 2
   • Tioconazole 1% lotion applied twice daily for 2-4 weeks 2

2. Other effective topical options:

   • Selenium sulfide 1% or 2.5% shampoo (apply to affected areas, leave on for 10 minutes, then rinse off)
   • Can be used daily for 7 days or weekly for maintenance therapy

Second-Line Treatment: Oral Antifungal Therapy

Reserved for patients with:

• Extensive disease
• Frequent recurrences
• Disease refractory to topical therapy

Options include:

1. Fluconazole:

   • 300 mg once weekly for 2 weeks (75% complete cure rate, 77.5% mycological cure rate) 3
   • Alternative: 400 mg as a single dose 4

2. Itraconazole:

   • 200 mg daily for 5-7 days 4

3. Ketoconazole (not FDA-approved for tinea versicolor):

   • Has been used orally with success but carries higher risk of hepatotoxicity 5

Prophylaxis for Recurrent Disease

• Long-term intermittent prophylactic therapy should be considered for patients with frequent recurrence
• Options include:
  • Selenium sulfide or ketoconazole shampoo applied to affected areas once monthly
  • Oral fluconazole 300 mg once monthly

Important Considerations

• Recurrence is common with tinea versicolor, even after successful treatment
• Complete resolution of pigmentary changes may take weeks to months after mycological cure
• Oral antifungals offer advantages of increased compliance, shorter treatment duration, and reduced recurrence rates but have higher cost and greater potential for adverse effects 1
• Terbinafine, while effective for many dermatophyte infections, appears ineffective for tinea versicolor when taken orally 4

Treatment Selection Factors

When choosing between treatment options, consider:

• Extent and severity of infection
• Patient compliance factors
• Previous treatment history
• Cost considerations
• Potential for drug interactions

The most recent evidence suggests that topical therapy should be the first approach for most patients with tinea versicolor, with oral therapy reserved for specific situations where topical treatment is impractical or has failed.