What is the treatment for Pityriasis versicolor?

Treatment of Pityriasis Versicolor

Topical antifungal medications are the first-line treatment for pityriasis versicolor, with oral antifungals reserved for severe, widespread, or recalcitrant cases. Pityriasis versicolor (tinea versicolor) is a common superficial fungal infection caused by Malassezia species that typically presents with hypopigmented or hyperpigmented macules on the trunk, neck, or upper arms.

First-Line Treatment Options

Topical Antifungals

• Azoles:

  • Clotrimazole cream applied twice daily for 2 weeks (94.9% complete resolution at 4 weeks) 1
  • Ketoconazole shampoo (leave on for 5 minutes before rinsing, daily for 3-5 days)

• Allylamines:

  • Terbinafine 1% cream or emulsion gel (Lamisil DermGel) once daily for 7 days (75% cure rate) 2

• Other effective topical options:

  • Selenium sulfide 2.5% shampoo (leave on for 10 minutes before rinsing, daily for 7 days)
  • Zinc pyrithione shampoo
  • Propylene glycol 50% in water (apply twice daily for 2 weeks)

Second-Line Treatment Options (Severe or Widespread Disease)

Oral Antifungals

• Fluconazole: 400 mg single dose (65% culture negative at 8 weeks) 3

  • Lower relapse rate compared to itraconazole (35% vs 60%) 3

• Itraconazole: 400 mg single dose or 200 mg daily for 5-7 days

Treatment Algorithm

1. For limited disease:

   • Start with topical therapy for 2 weeks
   • Clotrimazole cream twice daily OR ketoconazole shampoo daily OR terbinafine 1% cream daily

2. For extensive disease or treatment failure:

   • Single dose fluconazole 400 mg OR
   • Itraconazole 200 mg daily for 5-7 days

3. For recurrent cases:

   • Consider prophylactic therapy with ketoconazole shampoo once weekly OR
   • Monthly single-dose fluconazole 400 mg

Important Clinical Considerations

• Diagnosis confirmation: Before starting treatment, confirm diagnosis with KOH preparation showing characteristic "spaghetti and meatballs" appearance (hyphae and yeast cells) 4

• Patient education:

  • Inform patients that skin color may take weeks to months to normalize after successful treatment
  • The fungus is part of normal skin flora, so recurrence is common (40-60%)

• Treatment response evaluation:

  • Assess at 2-4 weeks after completing therapy
  • Clinical improvement precedes color normalization

• Recurrence prevention:

  • Address predisposing factors: high humidity, hyperhidrosis, immunosuppression
  • Consider prophylactic treatment in patients with frequent recurrences

Treatment Pitfalls to Avoid

1. Inadequate treatment duration: Stopping treatment too early may lead to recurrence

2. Misinterpreting persistent dyspigmentation: Skin color may take weeks to months to normalize even after successful eradication of the fungus

3. Neglecting prophylaxis: For patients with frequent recurrences, prophylactic treatment is essential

4. Overuse of oral antifungals: Reserve systemic therapy for extensive disease or when topical treatments have failed

5. Ignoring predisposing factors: High humidity, excessive sweating, and immunosuppression contribute to recurrence

In conclusion, pityriasis versicolor is effectively treated with topical antifungals in most cases, with oral antifungals reserved for severe or recalcitrant disease. Prophylactic treatment should be considered for patients with frequent recurrences, as the condition has a high tendency to relapse due to the presence of Malassezia as part of the normal skin flora 4, 5.