Treatment for Tinea Versicolor
For tinea versicolor, use topical selenium sulfide 2.5% applied daily for 7 days as first-line therapy, reserving oral itraconazole 200 mg daily for 5-7 days for extensive disease or topical treatment failures. 1, 2, 3
First-Line Topical Treatment
- Apply selenium sulfide 2.5% to affected areas, lather with small amount of water, leave on skin for 10 minutes, then rinse thoroughly—repeat daily for 7 consecutive days. 1
- Topical agents are effective for most cases and help reduce transmission of spores. 2
- Remove jewelry before application as selenium sulfide may damage it. 1
- Wash hands thoroughly after each application. 1
Oral Therapy for Extensive or Resistant Disease
When topical treatment fails or disease is widespread, oral antifungals are indicated. 2
Recommended Oral Regimens (in order of preference):
- Itraconazole 200 mg daily for 5-7 days is the most evidence-based systemic option, with 89-94% mycological cure rates and excellent tolerability. 4, 3
- Fluconazole 300 mg weekly for 2 weeks is an alternative with similar efficacy to ketoconazole but better safety profile. 3, 5
- Itraconazole 50-100 mg daily for 2-4 weeks can be considered for resistant cases. 2
Important Considerations for Oral Therapy:
- Itraconazole has significant drug interactions with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin—review medication list before prescribing. 6
- Ketoconazole is not recommended as first-line due to hepatotoxicity concerns, though it remains effective. 7, 3
- Short-term oral azole therapy (5-7 days) is as effective as longer courses, improving compliance. 4, 3
Treatment Monitoring and Follow-Up
- The definitive endpoint must be mycological cure, not just clinical improvement. 2
- Perform follow-up with both clinical and mycological assessment (KOH preparation) to confirm clearance. 2
- Maximal cure rates are achieved at 8 weeks from treatment initiation. 5
- Wood's lamp examination can be useful for detecting cure. 5
Critical Pitfall:
- Hypopigmentation persists after mycological cure and does not indicate treatment failure—this is a common source of patient dissatisfaction. 8
- Repigmentation occurs gradually over months after fungal clearance; patients must understand this is normal. 8
Prevention of Recurrence
Recurrence is extremely common with tinea versicolor, so implement these measures:
- Clean all contaminated combs, brushes, and personal items with 2% sodium hypochlorite solution or bleach. 6, 2
- Avoid sharing towels and personal items. 6
- Cover lesions during active infection. 6
- Consider prophylactic selenium sulfide application monthly in high-risk patients (tropical climates, recurrent disease). 7
Treatment Algorithm Summary
- Limited disease: Selenium sulfide 2.5% daily × 7 days 1
- Extensive disease or topical failure: Itraconazole 200 mg daily × 5-7 days 3
- Drug interactions with itraconazole: Fluconazole 300 mg weekly × 2 weeks 3
- Confirm mycological cure at 4-8 weeks post-treatment 2, 5
- Counsel about delayed repigmentation 8