What is the treatment for pityriasis versicolor?

Treatment of Pityriasis Versicolor

For pityriasis versicolor, topical azole antifungals (ketoconazole shampoo or cream) or selenium sulfide are first-line treatments, with single-dose oral fluconazole 400 mg reserved for extensive or recurrent disease.

First-Line Topical Treatment Options

Topical therapy should be the initial approach for most patients with pityriasis versicolor. 1 The following options are equally effective:

• Ketoconazole 2% shampoo: Apply to affected areas, lather with small amount of water, leave on for 5-10 minutes, then rinse thoroughly; use daily for 1-2 weeks 1
• Selenium sulfide 2.5% lotion: Apply to affected areas, lather with small amount of water, allow to remain on skin for 10 minutes, then rinse body thoroughly; repeat once daily for 7 days 2
• Other topical azoles (bifonazole, econazole): Apply twice daily for 2-4 weeks 1, 3
• Terbinafine 1% cream or gel (Lamisil DermGel): Apply once daily for 7 days, achieving 75% cure rates 4

Important caveat: Pooled evidence shows no significant difference in clinical cure rates between azole preparations and keratolytic agents like selenium sulfide (RR 0.99,95% CI 0.88-1.12), though this is very low-quality evidence 3. Both are reasonable first-line choices based on availability and cost.

Systemic Therapy for Extensive or Recurrent Disease

When topical therapy fails or disease is widespread, oral antifungals are highly effective:

• Fluconazole 400 mg as a single oral dose is the preferred systemic option 1, 5, 6
• Itraconazole 200 mg daily for 5-7 days is an alternative 1, 5

Fluconazole is superior to itraconazole in head-to-head comparison: At 8 weeks, 65% of fluconazole-treated patients became culture-negative versus only 20% with itraconazole, and relapse rates were lower with fluconazole (35% vs 60%) 6. This makes fluconazole the clear choice when systemic therapy is needed.

Do not use oral terbinafine for pityriasis versicolor—it is ineffective against Malassezia species 5.

Prophylaxis to Prevent Recurrence

Recurrence is common and prophylactic treatment is mandatory to maintain clearance: 1

• Ketoconazole 2% shampoo: Apply once monthly to entire trunk and leave on for 5-10 minutes before rinsing 1
• Selenium sulfide lotion: Apply monthly using same technique as treatment 1
• Itraconazole 400 mg: Single dose monthly for maintenance (alternative approach) 5

Treatment Algorithm

1. For limited disease (<20% body surface area): Start with topical ketoconazole shampoo or selenium sulfide for 1-2 weeks 2, 1

2. For extensive disease (>20% body surface area) or treatment failure: Give single-dose fluconazole 400 mg orally 5, 6

3. After clinical clearance: Initiate monthly prophylaxis with topical ketoconazole shampoo or selenium sulfide to prevent recurrence 1

4. For recurrent disease despite prophylaxis: Consider monthly oral fluconazole 400 mg or itraconazole 400 mg 5

Critical Pitfalls to Avoid

• Do not expect immediate cosmetic improvement: Hypopigmented patches may persist for months after fungal eradication due to residual melanocyte dysfunction; this does not indicate treatment failure 1
• Do not confuse with vitiligo: Pityriasis versicolor shows fine scale on scraping and positive KOH preparation, while vitiligo does not 7
• Warn patients about jewelry damage: Selenium sulfide can damage jewelry; patients should remove all jewelry before application 2
• Address predisposing factors: High temperature, humidity, hyperhidrosis, greasy skin, and immunosuppression increase recurrence risk 1