Treatment of Pityriasis Versicolor
Topical antifungal medications are the first-line treatment for pityriasis versicolor, with ketoconazole, selenium sulfide, and zinc pyrithione being the most effective options. 1
First-Line Topical Treatment Options
For most cases of pityriasis versicolor, start with one of these topical agents:
- Selenium sulfide: Apply to affected areas, lather with small amount of water, leave on skin for 10 minutes, then rinse thoroughly; repeat once daily for 7 days 2
- Ketoconazole shampoo: Effective topical option with strong evidence base 1, 3
- Zinc pyrithione shampoo: Another effective first-line topical choice 1, 3
- Terbinafine topical: Proven efficacy as first-line treatment 1
These topical agents are preferred because they directly target Malassezia species on the skin surface with minimal systemic absorption and excellent safety profiles. 1
When to Use Oral Antifungal Therapy
Reserve systemic treatment for severe, extensive, or recalcitrant cases that fail topical therapy. 1
Effective Oral Regimens:
- Itraconazole 400 mg daily for 3 days: As effective as the traditional 200 mg daily for 5 days regimen 4
- Itraconazole 200 mg daily for 5-7 days: Traditional effective regimen 4, 5
- Fluconazole 400 mg as a single dose: Highly effective option 5
Important caveat: Oral terbinafine is NOT effective for pityriasis versicolor and should not be prescribed, despite its efficacy for other fungal infections. 1 Additionally, oral ketoconazole should no longer be used due to safety concerns. 1
Alternative Topical Options
Other topical agents with documented efficacy include:
- Propylene glycol 3
- Ciclopiroxamine 3
- Topical azoles (bifonazole, econazole) - though evidence suggests they may not differ significantly from keratolytic agents 6
Prophylactic/Maintenance Therapy
Because Malassezia is part of normal skin flora, recurrence rates are high, making prophylactic treatment important. 1, 3
- Consider maintenance therapy to prevent recurrent infections, though research on optimal prophylactic regimens remains limited 1
- Prophylactic treatment is mandatory to avoid recurrence 3
Key Clinical Pitfalls to Avoid
- Do not prescribe oral terbinafine - it is ineffective for pityriasis versicolor despite working for other dermatophyte infections 1
- Do not use oral ketoconazole - safety concerns have eliminated this as a treatment option 1
- Itraconazole 400 mg for only 1 day is ineffective - minimum 3-day course required 4
- Address predisposing factors: high temperatures, humidity, greasy skin, hyperhidrosis, and immunodeficiency all increase recurrence risk 3
Distinguishing from Vitiligo
Pityriasis versicolor can be distinguished from vitiligo by the presence of fine scale on scraping and positive KOH preparation, whereas vitiligo lacks these features. 7