What is the treatment for tinea versicolor?

Treatment of Tinea Versicolor

For tinea versicolor, topical antifungal therapy is first-line treatment, with terbinafine 1% cream applied once daily for 1-2 weeks being highly effective, or alternatively selenium sulfide lotion applied for 10 minutes daily for 7 days. 1, 2

Topical Treatment Options (First-Line)

Terbinafine

• Apply terbinafine 1% cream once daily for 1-2 weeks to affected areas 1
• This is the preferred topical agent based on current evidence

Selenium Sulfide

• Apply to affected areas, lather with small amount of water, allow to remain on skin for 10 minutes, then rinse thoroughly 2
• Repeat once daily for 7 days 2
• Traditional agent that remains effective, though recurrence rates may be higher than with azole antifungals 3
• Remove jewelry before use as product may cause damage 2

Other Topical Azoles

• Ketoconazole shampoo is effective and widely used 4
• Zinc pyrithione shampoo provides another option 4, 5
• Clotrimazole 1% solution applied twice daily for 28 days achieves clinical and mycological cure 6

Oral Antifungal Therapy (For Extensive or Recalcitrant Disease)

Fluconazole (Preferred Oral Agent)

• Single dose of 400 mg fluconazole is highly effective 7
• Alternative regimen: 150 mg once weekly for 2-3 weeks 7
• Well-tolerated with favorable safety profile 5

Itraconazole (Alternative Oral Agent)

• 200 mg daily for 5-7 days 7, 5
• Alternative regimen: 100 mg daily for 2 weeks 7
• Effective for severe or recalcitrant cases 5

Avoid Oral Terbinafine

• Oral terbinafine is NOT effective for tinea versicolor and should not be used 5
• This is a critical pitfall to avoid, as terbinafine works well topically but fails systemically for this condition

Ketoconazole Oral Therapy

• Oral ketoconazole should no longer be prescribed due to hepatotoxicity risk 1, 5
• Has been withdrawn in some countries due to liver toxicity concerns 1

Essential Adjunctive Measures

• Complete drying of affected areas after bathing is mandatory to prevent recurrence 1
• Use separate towels for affected areas versus other body parts to reduce contamination 1
• These hygiene measures are critical as recurrence rates are high even with effective treatment 3, 4

Prophylactic/Maintenance Therapy

• Consider prophylactic antifungal treatment to prevent recurrent infection, though evidence is limited 5
• Recurrence is common due to Malassezia being part of normal skin flora 4, 5
• Prophylactic regimens may include periodic application of topical agents or intermittent oral therapy 5

Treatment Algorithm

1. For localized disease: Start with topical terbinafine 1% cream once daily for 1-2 weeks OR selenium sulfide lotion daily for 7 days 1, 2

2. For extensive or treatment-resistant disease: Use oral fluconazole 400 mg single dose OR itraconazole 200 mg daily for 5-7 days 7, 5

3. Implement hygiene measures: Ensure complete drying after bathing and use separate towels 1

4. For recurrent disease: Consider maintenance therapy with periodic topical or oral antifungal agents 5

Common Pitfalls to Avoid

• Never prescribe oral terbinafine for tinea versicolor—it is ineffective despite topical terbinafine being highly effective 5
• Avoid oral ketoconazole due to hepatotoxicity risk 1, 5
• Do not rely solely on clinical clearance—mycological cure is important to prevent rapid recurrence 3
• Warn patients that pigmentary changes may persist for weeks to months after successful treatment, which does not indicate treatment failure 3