What is the treatment for pityriasis versicolor?

Treatment of Pityriasis Versicolor

For pityriasis versicolor, use topical selenium sulfide applied daily for 7 days as first-line treatment, or alternatively use topical azole antifungals (ketoconazole, bifonazole, or econazole) for 2-4 weeks, with oral fluconazole 400 mg as a single dose reserved for extensive or recalcitrant cases.

Topical Treatment Options

Keratolytic Agents

• Selenium sulfide is an FDA-approved first-line option: apply to affected areas, lather with small amount of water, allow to remain on skin for 10 minutes, then rinse thoroughly, repeating once daily for 7 days 1
• Other keratolytic options include propylene glycol, zinc pyrithione shampoo, and salicylic-benzoic acid preparations 2
• These agents are inexpensive, readily available over-the-counter, and do not induce resistant fungal strains 3

Topical Antifungal Agents

• Azole preparations (ketoconazole shampoo, bifonazole, econazole) achieve clinical cure rates comparable to keratolytic agents, with no significant difference in efficacy (RR 0.99) or adverse events (RR 0.59) 3
• Terbinafine 1% cream applied for 2-4 weeks achieves cure rates of 79-100% 4
• Terbinafine 1% emulsion gel (DermGel) applied once daily for only 7 days achieves 75% cure rate versus 14% with placebo, with the advantage of remaining in skin at high concentrations for months after application 4
• Ciclopiroxamine is another effective topical option 2

Oral Systemic Therapy

When to Use Systemic Treatment

• Reserve oral antifungals for extensive disease, treatment failures with topical therapy, or when topical application is impractical 2, 5

Oral Antifungal Regimens

• Fluconazole 400 mg as a single oral dose is highly effective and superior to itraconazole at the same dosing, with lower relapse rates (35% vs 60%) and higher culture negativity at 8 weeks (65% vs 20%) 6
• Itraconazole 200 mg daily for 5-7 days is an alternative option 5
• Oral terbinafine is ineffective for pityriasis versicolor and should not be used 5

Prophylaxis and Recurrence Prevention

• Prophylactic treatment regimens are mandatory to prevent recurrence, as pityriasis versicolor has high recurrence rates 2
• The high relapse rate correlates directly with persistence of Malassezia furfur in perilesional skin 6
• Consider maintenance therapy with periodic application of topical agents, particularly in patients with predisposing factors (high temperature/humidity environments, hyperhidrosis, greasy skin, corticosteroid use, immunodeficiency) 2

Diagnostic Confirmation

• Confirm diagnosis with KOH preparation showing characteristic "spaghetti and meatballs" appearance, which distinguishes pityriasis versicolor from vitiligo 7
• Fine scale on scraping is present in pityriasis versicolor but absent in vitiligo 7

Treatment Algorithm

1. For localized disease: Start with selenium sulfide 10-minute application daily for 7 days 1, or terbinafine 1% emulsion gel once daily for 7 days 4
2. For moderate disease or topical treatment failure: Use ketoconazole shampoo or other azole preparations for 2-4 weeks 2, 3
3. For extensive or recalcitrant disease: Administer fluconazole 400 mg as single oral dose 6
4. For all patients: Implement prophylactic maintenance regimen to prevent recurrence 2

Common Pitfalls

• Avoid oral terbinafine, as it lacks efficacy against Malassezia species despite effectiveness for dermatophyte infections 5
• Do not discontinue prophylaxis prematurely, as recurrence is common without maintenance therapy 2
• Two patients treated with selenium sulfide developed acute dermatitis requiring discontinuation, so monitor for irritant reactions 3