Can pityriasis versicolor present without scaling?

Can Pityriasis Versicolor Present Without Scaling?

Yes, pityriasis versicolor can occasionally present without scaling, though scaling is a characteristic feature in most cases. While fine scaling is typically present in pityriasis versicolor lesions, the clinical presentation can vary, and in some cases, the scaling may be minimal or absent, making diagnosis challenging 1.

Clinical Presentation of Pityriasis Versicolor

Pityriasis versicolor (also known as tinea versicolor) is a common superficial fungal infection caused by Malassezia species. Its typical presentation includes:

• Multiple small, scaly macules that often coalesce to form larger patches 1
• Hypopigmented, hyperpigmented, or erythematous lesions 1, 2
• Predilection for the upper trunk, neck, shoulders, upper arms, and chest 2, 3
• Fine scaling on the surface of lesions in most cases 1

Atypical Presentations

Several factors can affect the clinical appearance of pityriasis versicolor:

• In moist areas such as skin folds, scaling may be minimal or absent (similar to how inverse psoriasis presents with minimal scaling in skin folds) 4
• Recent bathing or sweating may temporarily remove visible scales
• Early lesions may not yet have developed noticeable scaling
• In some variants, such as the rare atrophic form, the clinical presentation may be atypical 5

Diagnostic Approach When Scaling is Absent

When pityriasis versicolor presents without obvious scaling, diagnosis becomes more challenging. Consider these diagnostic methods:

1. Wood's light examination: May show yellowish or golden fluorescence 1
2. KOH preparation: Even in cases with minimal visible scaling, microscopy often reveals the characteristic "spaghetti and meatballs" appearance (short hyphae and round yeast cells) 1, 3
3. Dermatoscopy: Can show fine scaling that may not be visible to the naked eye and altered pigmentation patterns 1
4. Gentle scraping: Sometimes scales become more apparent after gentle scraping of the lesion surface

Differential Diagnosis

When scaling is absent, pityriasis versicolor may be confused with:

• Vitiligo (has sharp borders without scaling) 1
• Pityriasis alba (typically affects the face with less distinct borders) 1
• Post-inflammatory hypopigmentation (history of preceding inflammation) 1
• Seborrheic dermatitis (more pronounced inflammation) 1

Management Implications

Even when scaling is minimal or absent, treatment approach remains the same:

• Topical antifungals are first-line for limited disease: zinc pyrithione, ketoconazole, terbinafine 1, 6
• For extensive or recalcitrant cases: oral antifungals like itraconazole or fluconazole 6
• Prophylactic treatment should be considered for recurrent cases 6, 7

Clinical Pitfalls and Caveats

• Don't rule out pityriasis versicolor solely based on absence of scaling
• Perform KOH examination even when scaling is not visible
• Remember that recent bathing may temporarily remove scales
• Consider the diagnosis particularly in patients with risk factors: excessive sweating, oily skin, occlusive clothing, and family history 3
• Be aware that the condition has a high recurrence rate, so prophylactic treatment may be necessary 6, 7