What is the treatment for Tinea versicolor?

Treatment of Tinea Versicolor

Topical antifungal therapy is the first-line treatment for tinea versicolor, with selenium sulfide, ketoconazole, or zinc pyrithione being the most effective options for localized disease. 1, 2

First-Line Topical Treatment

• Selenium sulfide should be applied to affected areas, lathered with a small amount of water, allowed to remain on skin for 10 minutes, then rinsed thoroughly once daily for 7 days 1
• Topical ketoconazole and zinc pyrithione are equally effective alternatives for first-line therapy 2
• Topical agents help reduce transmission of spores and are effective for most cases 3
• Remove jewelry before application as selenium sulfide may damage it 1

Systemic Treatment for Extensive or Resistant Disease

When topical therapy fails or disease is extensive, oral antifungals are indicated:

Preferred Oral Regimens

• Itraconazole 200 mg daily for 5-7 days is highly effective and supported by strong evidence 4, 5
• Fluconazole 300 mg weekly for 2 weeks is an alternative evidence-based regimen 4
• Itraconazole 50-100 mg daily for 2-4 weeks can be used for extensive disease or cases resistant to topical therapy 3

Important Caveat About Oral Terbinafine

• Oral terbinafine is NOT effective for tinea versicolor and should not be prescribed for this condition 2, 5
• This is a critical distinction from other tinea infections where terbinafine is highly effective

Treatment Selection Algorithm

For localized disease:

• Start with topical selenium sulfide for 7 days 1
• Alternative: topical ketoconazole or zinc pyrithione 2

For extensive disease, treatment failure, or frequent recurrences:

• Use itraconazole 200 mg daily for 5-7 days 4
• Alternative: fluconazole 300 mg weekly for 2 weeks 4

For recurrent infections:

• Consider long-term intermittent prophylactic therapy 6
• Clean contaminated combs, brushes, and personal items properly 3

Follow-Up and Monitoring

• Follow-up should include both clinical and mycological assessment to confirm clearance 3
• Recurrence is common due to Malassezia being part of normal skin flora 2, 6
• Prophylactic maintenance therapy may be necessary for patients with frequent recurrences 6

Common Pitfalls to Avoid

• Do not prescribe oral ketoconazole due to hepatotoxicity risk; it should no longer be used for this indication 7
• Do not use oral terbinafine as it is ineffective against Malassezia species 2, 5
• Ensure proper cleaning of fomites and personal items to prevent reinfection 3
• Warn patients that repigmentation may take weeks to months after successful mycological cure 6