Treatment of Tinea Versicolor
For tinea versicolor, use topical selenium sulfide 2.5% applied daily for 10 minutes then rinsed off for 7 consecutive days as first-line therapy, or alternatively use oral azole antifungals (itraconazole 200mg daily for 5-7 days or fluconazole 400mg single dose) for extensive disease or treatment failures. 1
Topical Treatment (First-Line)
Selenium sulfide 2.5% is the FDA-approved topical treatment of choice:
- Apply to affected areas and lather with small amount of water 1
- Allow product to remain on skin for 10 minutes 1
- Rinse body thoroughly 1
- Repeat once daily for 7 consecutive days 1
- Remove jewelry before application as product may cause damage 1
- Wash hands well after treatment 1
Alternative topical agents include ketoconazole shampoo, zinc pyrithione shampoo, ciclopiroxamine, and topical azole antifungals, though these are effective with higher recurrence rates compared to systemic therapy 2, 3
Systemic Treatment (For Extensive Disease or Topical Failures)
Itraconazole dosing options:
- Single dose: 400mg once, repeated weekly for 2 weeks 4
- Standard course: 200mg daily for 5-7 days 5
- Both regimens show equivalent efficacy with 73-80% cure rates and 90-93% overall response rates 6
Fluconazole dosing options:
- Single dose: 400mg once as single treatment 5
- Alternative: 150mg weekly for 2 weeks 4
- Demonstrates similar efficacy to itraconazole with excellent tolerability 4
Ketoconazole (200mg twice weekly for 2 weeks) is effective but carries higher hepatotoxicity risk compared to newer triazoles and is not FDA-approved for this indication 2, 4
Treatment Selection Algorithm
- Limited disease (<20% body surface area): Start with topical selenium sulfide for 7 days 1
- Extensive disease or frequent relapses: Use oral itraconazole 200mg daily for 5-7 days or fluconazole 400mg single dose 5
- Treatment failures with topicals: Switch to systemic azole therapy 2, 3
- Cost-conscious patients: Single-dose itraconazole 400mg improves compliance and decreases treatment cost 6
Important Clinical Considerations
Maximal cure rates are achieved at 8 weeks from treatment initiation, not at end of therapy 4
Hypopigmentation persists after mycological cure and does not correlate with treatment failure—repigmentation may take months after successful eradication 4
Prophylactic maintenance therapy is mandatory to prevent recurrence, as this is a chronically recurring disease with high relapse rates even after successful treatment 3
Terbinafine is ineffective for tinea versicolor and should not be used, unlike its efficacy in dermatophyte infections 5
Wood's lamp examination is useful for detecting cure and monitoring treatment response 4