How do I treat Tinea versicolor?

Treatment of Tinea Versicolor

For tinea versicolor, topical ketoconazole 2% shampoo is the first-line treatment, applied once daily for 1-3 days. 1

First-Line Topical Options

Ketoconazole 2% Shampoo

• Apply to affected areas, lather with water
• Leave on for 5-10 minutes, then rinse thoroughly
• Use either as:
  • Single application (1 day) regimen
  • Daily application for 3 days
• Both regimens show similar efficacy with clinical response rates of 69-73% 2
• Well-tolerated with minimal side effects

Selenium Sulfide

• Apply to affected areas and lather with water
• Allow to remain on skin for 10 minutes, then rinse thoroughly
• Use once daily for 7 days 3
• Traditional effective option but may have higher recurrence rates 4

Oral Treatment Options (for extensive or resistant cases)

Fluconazole

• Dosage: 300mg once weekly for 2 weeks
• Achieves 75% complete cure rate and 77.5% mycological cure by week 4 5
• No recurrence observed at 12-week follow-up
• Well-tolerated with minimal side effects

Ketoconazole (Oral)

• Dosage: 400mg single dose repeated weekly for 2 weeks
• Similar efficacy to fluconazole 6
• Caution: Oral ketoconazole has been withdrawn in many countries due to risk of hepatotoxicity

Treatment Algorithm

1. Limited disease:

   • Start with topical ketoconazole 2% shampoo (1-3 day regimen)
   • Alternative: selenium sulfide daily for 7 days

2. Extensive disease or treatment failure:

   • Consider oral fluconazole 300mg once weekly for 2 weeks

3. Follow-up:

   • Clinical improvement expected within 2-4 weeks
   • Note that hypopigmentation may persist for weeks to months after successful treatment 6

Important Considerations

• Hypopigmented or hyperpigmented patches may persist for weeks to months after successful treatment of the infection
• Wood's lamp examination can be useful for monitoring treatment response 6
• Recurrence is common, so preventive measures are important

Prevention of Recurrence

• Avoid excessive heat and humidity when possible
• Use antifungal shampoo (ketoconazole 2%) periodically as prophylaxis
• Wear loose-fitting, breathable clothing
• Avoid sharing personal items like clothing and towels

Common Pitfalls

1. Mistaking persistent hypopigmentation for active infection - Skin color changes may persist long after the fungus is eradicated
2. Inadequate treatment duration - Complete the full course even if symptoms improve
3. Failure to address risk factors - Hot, humid environments and excessive sweating can lead to recurrence
4. Confusing with other conditions - Tinea versicolor can be confused with vitiligo, pityriasis rosea, or seborrheic dermatitis

The maximal cure rate is typically achieved at 8 weeks from the start of treatment 6, so patience is required when evaluating treatment success.