What is the treatment for pityriasis versicolor patches grouped together?

Treatment of Pityriasis Versicolor

The most effective treatment for pityriasis versicolor is topical ketoconazole 2% cream applied once daily for two weeks, which is FDA-approved specifically for this condition and provides excellent clinical outcomes with minimal side effects. 1

Clinical Presentation and Diagnosis

Pityriasis versicolor (tinea versicolor) is a common superficial fungal infection caused by the lipophilic yeast Malassezia (also known as Pityrosporum ovale or P. orbiculare). It typically presents as:

• Multiple hypopigmented or hyperpigmented macules that may coalesce
• Fine scaling patches, often on the upper trunk, neck, and upper arms
• Mild pruritus in some cases
• More prominent in warm, humid environments

Diagnosis is typically confirmed by:

• Direct microscopy with potassium hydroxide (KOH) preparation showing characteristic "spaghetti and meatballs" appearance (hyphae and yeast cells)
• Wood's lamp examination may show yellow-gold fluorescence

Treatment Algorithm

First-Line Treatment:

• Topical ketoconazole 2% cream applied once daily for two weeks 1
  • FDA-approved specifically for tinea versicolor
  • Clinical improvement may be seen fairly soon after treatment begins
  • Complete the full two-week course to reduce recurrence risk

Alternative Topical Options:

• Selenium sulfide shampoo (2.5%) applied to affected areas for 10 minutes daily for 7 days
• Zinc pyrithione shampoo
• Ciclopiroxamine cream
• Propylene glycol solution

For Extensive or Recalcitrant Cases:

1. Fluconazole 300mg once weekly for 2 weeks combined with ketoconazole 2% foam twice weekly

   • Shown to have the highest clinical cure rate (62.4%) in comparative studies 2

2. Single-dose fluconazole 400mg

   • More effective than single-dose itraconazole with lower relapse rates (35% vs 60%) 3

3. Itraconazole options:

   • 200mg daily for 7 days (36.3% cure rate) 2
   • 400mg daily for 3 days (comparable efficacy to 200mg daily for 5 days) 4

Special Considerations

• Predisposing factors that should be addressed:

  • High temperatures and humidity
  • Greasy skin
  • Hyperhidrosis
  • Corticosteroid treatment
  • Immunodeficiency

• Prevention of recurrence:

  • Prophylactic treatment is mandatory to avoid recurrence 5
  • Options include monthly use of ketoconazole shampoo or periodic oral antifungal therapy during warm months

• Treatment failures:

  • Consider perilesional skin involvement as a source of relapse 3
  • Ensure adequate coverage of all affected and surrounding areas
  • Consider switching to a different antifungal class if initial treatment fails

Monitoring and Follow-up

• Clinical assessment at 4 weeks after treatment completion
• Evaluate for:
  • Resolution of hypopigmentation/hyperpigmentation
  • Absence of scaling
  • Resolution of pruritus
  • Negative KOH preparation if symptoms persist

Pitfalls and Caveats

• Pigmentary changes may persist for weeks to months after successful treatment
• Do not confuse with other conditions like vitiligo, seborrheic dermatitis, or pityriasis alba
• Relapse is common (up to 60% in some studies) and may require maintenance therapy
• Ketoconazole has better hepatic safety profile than older systemic antifungals 6
• When using oral antifungals, monitor for potential drug interactions and side effects

Remember that while the hypopigmentation or hyperpigmentation may take time to resolve even after successful treatment, the fungal infection itself should be eradicated with appropriate therapy.