Treatment of Pityriasis Versicolor
Topical ketoconazole 2% cream applied once daily for two weeks is the recommended first-line treatment for pityriasis versicolor. 1
Diagnosis
Before initiating treatment, it's important to confirm the diagnosis of pityriasis versicolor:
- Look for characteristic hypopigmented or hyperpigmented macules with fine scale, typically on the upper trunk, neck, or upper arms
- Perform microscopic examination (KOH preparation) or fungal culture to confirm the presence of Malassezia furfur (Pityrosporum orbiculare) 2
- The condition appears as short hyphae and round yeast cells ("spaghetti and meatballs" pattern) under microscopy
Treatment Options
First-Line Treatment:
- Topical ketoconazole 2% cream:
- Apply once daily to affected areas and immediate surrounding skin
- Continue for two weeks to reduce possibility of recurrence
- Clinical improvement may be seen fairly soon after treatment begins 1
Alternative Topical Options:
Terbinafine 1% cream:
Clotrimazole 1% cream:
Miconazole 2% cream:
- Apply twice daily for 2 weeks 2
Systemic Treatment (for extensive or recurrent cases):
Fluconazole:
- 400 mg as a single dose 5
Itraconazole:
- 200 mg daily for 5-7 days 5
Note: Oral terbinafine appears to be ineffective for pityriasis versicolor 5
Comparative Efficacy
A meta-analysis comparing azole preparations (ketoconazole, bifonazole, econazole) with keratolytic agents (selenium sulfide, adapalene, salicylic-benzoic acid) found no significant difference in clinical cure rates (RR 0.99,95% CI 0.88-1.12) 6
In a head-to-head comparison, ketoconazole 2% cream showed a 90% cure rate while clotrimazole 1% cream showed an 85% cure rate after 2 weeks of treatment, with no significant difference between the two 4
Prevention of Recurrence
Pityriasis versicolor has a high recurrence rate. To prevent recurrence:
- Apply antifungal powders containing miconazole or clotrimazole to susceptible areas 2
- Avoid excessive heat and humidity
- Wear loose-fitting, cotton clothing
- Consider prophylactic treatment during summer months for those with recurrent disease
Treatment Monitoring
- Continue treatment for the full recommended duration even if symptoms improve earlier
- Clinical improvement is typically expected within 1-2 weeks
- Pigmentary changes may persist for weeks to months after successful treatment of the infection
- Follow-up examination is recommended if symptoms persist after completing the full treatment course
Cautions
- Topical treatments are generally well-tolerated with minimal side effects
- Systemic treatments carry risks of adverse events including gastrointestinal disturbances and potential drug interactions
- Patients should be advised that even after successful treatment of the fungal infection, skin color may take several weeks or months to return to normal
Remember that pityriasis versicolor is caused by a yeast that naturally colonizes the skin, which explains its tendency to recur. Complete eradication is challenging, and maintenance therapy may be necessary for patients with frequent recurrences.