Treatment of Pityriasis Versicolor
Topical antifungal agents are the first-line treatment for pityriasis versicolor, with ketoconazole, selenium sulfide, and zinc pyrithione being the most effective options. 1
Diagnosis Confirmation
- Confirm diagnosis by scraping lesions to demonstrate fine scale and performing KOH preparation to visualize Malassezia yeast, which distinguishes pityriasis versicolor from vitiligo 2
- Look for characteristic hypo- or hyperpigmented patches with fine scale, typically on trunk and upper extremities 1
First-Line Topical Treatment Options
For localized disease, choose one of the following topical agents:
- Selenium sulfide 2.5% lotion/shampoo: Apply to affected areas, lather with small amount of water, leave on skin for 10 minutes, then rinse thoroughly; repeat daily for 7 days 3
- Ketoconazole 2% cream or shampoo: Apply once or twice daily for 2-4 weeks 1, 4
- Zinc pyrithione: Apply as directed, typically for 2-4 weeks 1
- Terbinafine cream: Apply once or twice daily for 2-4 weeks 1
The evidence comparing azoles to keratolytic agents (like selenium sulfide) shows no significant difference in clinical cure rates (RR 0.99), though the quality of evidence is very low 4. Both classes are equally effective, so selection can be based on cost, availability, and patient preference.
Systemic Treatment for Severe or Recalcitrant Disease
When topical therapy fails or disease is extensive, use oral antifungals:
- Fluconazole 400 mg as a single dose OR 150 mg once weekly for 2-3 weeks 5
- Itraconazole 200 mg daily for 5-7 days 5
Critical pitfall: Oral terbinafine is NOT effective for pityriasis versicolor and should never be prescribed for this condition 1, 5. Oral ketoconazole should no longer be used due to hepatotoxicity risk 1.
Recurrence Prevention
- Recurrence rates are high (up to 60-80% within 1-2 years) because Malassezia is part of normal skin flora 1, 6
- Consider maintenance therapy with monthly application of topical antifungals (ketoconazole shampoo or selenium sulfide) during warm/humid months 1
- Limited research exists on optimal prophylactic regimens, but clinical experience supports intermittent maintenance 1
Treatment Monitoring
- Assess clinical response at 2-4 weeks for topical therapy 1
- Mycological cure (negative KOH) may occur before clinical cure (pigment normalization) 7
- Warn patients that pigmentary changes may persist for months after successful fungal eradication, requiring continued sun protection and patience 1