What is the treatment for tinea versicolor?

Treatment of Tinea Versicolor

For tinea versicolor, ketoconazole 2% cream applied once daily for two weeks is the recommended first-line treatment, as it effectively targets the causative Malassezia fungus with minimal side effects. 1

Diagnosis Confirmation

• Diagnosis should be confirmed through:
  • Clinical presentation (hypopigmented or hyperpigmented scaly patches on upper trunk, neck, and arms)
  • Wood's lamp examination (yellowish fluorescence)
  • KOH microscopy (short hyphae and clusters of spores - "spaghetti and meatballs" appearance)

Treatment Options

Topical Treatments (First-Line)

1. Ketoconazole 2% cream:

   • Apply once daily to affected areas for two weeks 1
   • Clinical improvement may be seen soon after treatment begins
   • Continue for full two weeks to prevent recurrence

2. Ketoconazole 2% shampoo:

   • Single application: Apply to affected areas, leave for 5 minutes, then rinse
   • Three-day regimen: Apply daily for 3 consecutive days
   • Both regimens show similar efficacy (69-73% clinical response rate) 2
   • Convenient option for large body surface areas

3. Other topical options:

   • Terbinafine 1% cream once daily for 1-2 weeks 3
   • Clotrimazole 1% or miconazole 2% cream twice daily for 2 weeks 3

Systemic Treatments (For extensive disease or recurrent cases)

1. Itraconazole:

   • Option 1: Single 400mg dose (improves compliance, cost-effective) 4
   • Option 2: 200mg daily for 7 days 4
   • Both regimens show similar efficacy (90-93% response rate)

2. Fluconazole:

   • Two 150mg capsules as a single dose, repeated weekly for 2 weeks 5
   • Similar efficacy to ketoconazole with good safety profile

3. Ketoconazole (oral):

   • Two 200mg tablets as a single dose, repeated weekly for 2 weeks 5
   • Effective but carries higher risk of hepatotoxicity than newer azoles

Treatment Selection Algorithm

1. For limited disease:

   • Start with topical ketoconazole 2% cream once daily for 2 weeks 1
   • Alternative: ketoconazole 2% shampoo (single application or 3-day regimen) 2

2. For extensive disease:

   • Use systemic therapy with itraconazole (single 400mg dose or 200mg daily for 7 days) 4
   • Alternative: fluconazole (two 150mg capsules weekly for 2 weeks) 5

3. For recurrent cases:

   • Consider prophylactic therapy with intermittent topical or systemic antifungals 6

Important Clinical Pearls

• Hyperpigmentation or hypopigmentation may persist for weeks to months after successful treatment
• Mycological cure often precedes clinical resolution of pigmentary changes 5
• Recurrence is common, especially in tropical climates
• For frequent recurrences, consider prophylactic therapy with monthly topical applications or periodic oral doses 6

Prevention of Recurrence

• Avoid excessive heat and humidity when possible
• Use breathable fabrics
• Consider prophylactic treatment during warm months for those with frequent recurrences
• For severe or frequent recurrences, consider maintenance therapy with ketoconazole shampoo applied monthly