Treatment of Pityriasis Versicolor
Topical ketoconazole 2% cream applied once daily for two weeks is the first-line treatment for pityriasis versicolor, with oral azoles (fluconazole or itraconazole) reserved for severe or recalcitrant cases. 1
First-Line Topical Therapy
Topical antifungal agents are the primary treatment approach for pityriasis versicolor. 2
- Ketoconazole 2% cream should be applied once daily to the affected area and immediate surrounding skin for two weeks to reduce recurrence risk 1
- Alternative topical options include zinc pyrithione, terbinafine, selenium sulfide, and ciclopiroxamine 2, 3
- Ketoconazole shampoo can be used as a convenient alternative, particularly for widespread involvement 3
- Clinical improvement may appear early, but completing the full two-week course is essential to prevent relapse 1
Systemic Therapy for Severe or Recalcitrant Disease
When topical therapy fails or disease is extensive, oral azoles are highly effective. 2, 4
- Fluconazole 400 mg as a single dose is effective for pityriasis versicolor 4
- Itraconazole 200 mg daily for 5-7 days achieves high cure rates 4
- Short-term oral therapy with fluconazole or itraconazole is well-tolerated 3
Critical Pitfall to Avoid
- Never prescribe oral terbinafine for pityriasis versicolor—it is ineffective against Malassezia species 2, 4
- Oral ketoconazole should no longer be prescribed due to safety concerns 2
Prophylactic Maintenance Therapy
Recurrence rates remain high after successful treatment because Malassezia is part of normal skin flora. 2, 3
- Prophylactic regimens are useful for preventing recurrent infection, though evidence is limited 2
- Options include intermittent topical ketoconazole or selenium sulfide applications 3
- Consider monthly or bimonthly maintenance therapy in patients with frequent recurrences 3
Comparative Efficacy Evidence
Azole antifungals and keratolytic agents (like selenium sulfide) show similar clinical cure rates, though evidence quality is very low. 5
- Pooled data from 8 RCTs showed no significant difference in clinical cure between azoles and keratolytics (RR 0.99) 5
- Adverse events are uncommon with both approaches, though two cases of acute dermatitis occurred with selenium sulfide 5
- The choice between topical azoles and keratolytics can be based on cost, availability, and patient preference given equivalent efficacy 5
Diagnostic Confirmation
Before initiating treatment, confirm diagnosis with KOH preparation showing characteristic yeast and hyphae ("spaghetti and meatballs" appearance). 6
- Pityriasis versicolor shows fine scale on scraping and positive KOH preparation, distinguishing it from vitiligo 6