What is the treatment for tinea versicolor?

Treatment of Tinea Versicolor

For tinea versicolor, use topical selenium sulfide 2.5% shampoo applied daily for 7 days as first-line therapy, or alternatively ketoconazole 2% shampoo for 1-3 days; reserve oral azoles (fluconazole 400 mg single dose or itraconazole 200 mg daily for 5-7 days) for extensive disease or treatment failures. 1, 2, 3

Topical Therapy (First-Line)

Selenium Sulfide

• Apply to affected areas and lather with small amount of water, allow to remain on skin for 10 minutes, then rinse thoroughly 1
• Repeat once daily for 7 consecutive days 1
• Remove jewelry before application as product may cause damage 1
• Wash hands thoroughly after treatment 1

Ketoconazole 2% Shampoo

• Both single-day and 3-day regimens are highly effective with clinical response rates of 69% and 73% respectively at day 31 2
• Apply to affected areas, lather, leave on for 5-10 minutes, then rinse 2
• Either regimen: single application OR daily for 3 consecutive days 2
• No significant difference in efficacy between 1-day versus 3-day treatment 2
• Excellent safety profile with no serious adverse events reported 2

Other Topical Options

• Zinc pyrithione shampoo, ciclopiroxamine, or topical azole antifungals can be used as alternatives 4
• Propylene glycol is another effective topical option 4

Oral Therapy (For Extensive Disease or Treatment Failures)

Fluconazole (Preferred Oral Agent)

• 400 mg as a single oral dose 3, 5
• Alternative: 150 mg once weekly for 2 weeks 6
• Maximal cure rate achieved at 8 weeks from treatment initiation 6
• Can be used prophylactically to prevent recurrence in selected cases 5

Itraconazole (Alternative Oral Agent)

• 200 mg daily for 5-7 days 3, 4
• Alternative: 200 mg once weekly for 2 weeks 6
• Comparable efficacy to fluconazole 6

Ketoconazole (Oral - Less Preferred)

• 200 mg once weekly for 2 weeks 6
• Single 400 mg dose is effective 5
• Generally less preferred than fluconazole or itraconazole due to hepatotoxicity concerns

Important Clinical Considerations

When to Use Oral vs. Topical Therapy

• Topical therapy is difficult to apply over large body surface areas; oral agents are more practical for extensive involvement 4
• Reserve systemic therapy for widespread disease, treatment failures, or patient preference 3, 4

Terbinafine Is NOT Effective

• Oral terbinafine is ineffective for tinea versicolor and should not be used 3

Recurrence Prevention

• Prophylactic treatment regimens are mandatory to prevent recurrence 4
• Consider monthly application of topical agents or periodic oral azole dosing in patients with frequent recurrences 5, 4
• Address predisposing factors: high humidity, hyperhidrosis, greasy skin 4

Common Pitfalls

• Hypopigmentation may persist for months after mycological cure; this does not indicate treatment failure 6
• Wood's lamp examination can be useful for detecting cure, showing lack of correlation between mycological cure and persistent hypopigmentation at 2 weeks 6
• Recurrence is common due to environmental factors (heat, humidity) and endogenous factors (sebum production) 5, 4