Tinea Versicolor: Presentation and Treatment
Tinea versicolor typically presents with multiple small, scaly macules that coalesce into patches, appearing as hypopigmented, hyperpigmented, or erythematous lesions with fine scaling on the upper trunk, neck, and upper arms. 1
Clinical Presentation
Characteristic Features
- Multiple small patches grouped together (pathognomonic feature)
- Lesions may be:
- Hypopigmented (most common in dark-skinned individuals) 2
- Hyperpigmented
- Erythematous
- Fine scaling on the surface (may be minimal in moist areas)
- Common locations: upper trunk, neck, upper arms 3
- Usually asymptomatic, occasionally mildly pruritic
Diagnostic Methods
- Clinical appearance is often sufficient for diagnosis
- Wood's light examination: yellowish or golden fluorescence
- KOH preparation (most definitive): reveals characteristic "spaghetti and meatballs" appearance (short hyphae and round yeast cells) 1
- Dermatoscopy: shows fine scaling and altered pigmentation patterns
Pathophysiology
Tinea versicolor is caused by overgrowth of Malassezia species (primarily M. globosa, M. furfur, and M. sympodialis), which are lipophilic yeasts that normally inhabit human skin. 3
Predisposing factors include:
- High temperatures and humidity (more common in tropical regions)
- Greasy skin
- Hyperhidrosis
- Hereditary factors
- Corticosteroid treatment
- Immunodeficiency 4
Treatment Approach
First-Line Treatment: Topical Therapy
For limited disease:
- Selenium sulfide 2.5% lotion/shampoo: Apply to affected areas, lather with water, leave for 10 minutes, then rinse thoroughly. Repeat once daily for 7 days. 5
- Other effective topical options:
- Ketoconazole shampoo or cream
- Zinc pyrithione shampoo
- Terbinafine cream
- Ciclopiroxamine
- Propylene glycol 4
Second-Line Treatment: Oral Therapy
For extensive disease, frequent recurrences, or disease refractory to topical therapy:
- Fluconazole: 400mg single dose or 150mg weekly for 2-4 weeks
- Itraconazole: 200mg daily for 5-7 days 3
Prophylaxis for Recurrent Cases
- Monthly application of topical antifungals
- Periodic oral antifungal therapy (e.g., fluconazole 400mg monthly) 3
Important Clinical Considerations
Differential Diagnosis
- Vitiligo (sharp borders without scaling)
- Pityriasis alba (typically affects face with less distinct borders)
- Post-inflammatory hypopigmentation (history of preceding inflammation)
- Seborrheic dermatitis (more pronounced inflammation) 1
Treatment Pitfalls
- Persistence of pigmentary changes: Inform patients that color changes may persist for weeks to months after successful treatment
- High recurrence rate: Prophylactic regimens may be necessary for patients with frequent recurrences
- Treatment compliance: Topical treatments require proper application technique and adherence to the full treatment course
Monitoring
- Clinical improvement in scaling (usually within 1-2 weeks)
- Pigmentary changes may take months to resolve completely
- Consider prophylactic treatment for patients with frequent recurrences
Tinea versicolor is generally a benign condition with excellent response to appropriate therapy, though recurrences are common and may require long-term management strategies.