What is the best treatment for Tinea (ringworm) vesicolor?

Treatment of Tinea Versicolor

For tinea versicolor, topical therapy with selenium sulfide 2.5% lotion applied daily for 7 days or ketoconazole 2% shampoo for 1-3 days is first-line treatment, with oral azoles (fluconazole or itraconazole) reserved for extensive disease or topical treatment failures.

First-Line Topical Treatment Options

Selenium Sulfide 2.5% Lotion

• Apply to affected areas, lather with small amount of water, leave on skin for 10 minutes, then rinse thoroughly 1
• Use once daily for 7 consecutive days 1
• Has cytostatic effect on epidermal cells, reducing corneocyte production 1
• Contraindicated in pregnancy (Category C) and when acute inflammation or exudation is present due to increased absorption risk 1
• Remove jewelry before application as product may cause damage 1

Ketoconazole 2% Shampoo

• Highly effective with 73% clinical response rate when used daily for 3 days, or 69% when used as single application 2
• Apply to affected areas, leave on for prescribed duration, then rinse 2
• Both 1-day and 3-day regimens show similar efficacy and are significantly superior to placebo (P < .001) 2
• No serious adverse events reported in clinical trials 2

Terbinafine 1% Cream

• Apply once daily for 1-2 weeks to affected areas 3
• Note: Oral terbinafine is ineffective for tinea versicolor, unlike its efficacy in dermatophyte infections 4

Systemic Treatment for Extensive or Resistant Disease

Fluconazole (Preferred Oral Agent)

• 400 mg as single oral dose achieves 100% clinical cure and 92% mycological cure rates 5
• Alternative regimen: 150 mg once weekly for 2 weeks 6
• Maximal cure rate achieved at 8 weeks from treatment start 6
• Well-tolerated with no significant side effects in clinical studies 5

Itraconazole (Alternative Oral Agent)

• 50-100 mg daily for 2-4 weeks for extensive disease or topical therapy failures 7
• Alternative regimen: 200 mg daily for 5-7 days 4
• Similar efficacy and safety profile to fluconazole 6

Ketoconazole Oral (Not Recommended)

• Avoid due to hepatotoxicity risk, leading to withdrawal in some countries 3
• Despite historical use (200 mg weekly for 2 weeks showing similar efficacy to fluconazole), safety concerns preclude routine use 6

Critical Management Principles

Preventing Recurrence

• Complete drying of affected areas after bathing is essential to prevent recurrence 3
• Use separate towels for affected areas versus other body parts to reduce contamination 3
• Clean contaminated personal items properly 7

Follow-Up Strategy

• Include both clinical and mycological assessment 7
• Important caveat: Hypopigmentation may persist after mycological cure and does not indicate treatment failure 6
• Wood's lamp examination can be useful for detecting cure 6

Common Pitfalls to Avoid

• Do not use selenium sulfide when acute inflammation is present, as absorption increases 1
• Do not prescribe oral terbinafine for tinea versicolor—it is ineffective despite efficacy in dermatophyte infections 4
• Do not interpret persistent hypopigmentation as treatment failure; repigmentation occurs gradually after fungal eradication 6
• Avoid oral ketoconazole due to hepatotoxicity concerns 3