Treatment of Tinea Versicolor
For tinea versicolor, start with topical antifungal therapy as first-line treatment, reserving oral antifungals for extensive disease, treatment failures, or frequent recurrences. 1, 2
First-Line Topical Treatment
Topical antifungals are the treatment of choice due to their superior safety profile, fewer drug interactions, and lower cost compared to systemic therapy. 1
Recommended Topical Agents:
Selenium sulfide shampoo: 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. 3
Ketoconazole 2% shampoo or cream: Highly effective topical option with excellent cure rates. 4, 2
Zinc pyrithione: Another effective first-line topical agent. 2
Topical terbinafine: Proven efficacy for tinea versicolor treatment. 2
Important caveat: While traditional agents like selenium sulfide are effective, recurrence following topical treatment is common and often rapid. 4
Oral Antifungal Therapy
Reserve systemic treatment for patients with extensive disease, frequent recurrences, or disease refractory to topical therapy. 1, 2
Oral Treatment Options:
Itraconazole 50-100 mg daily for 2-4 weeks for extensive or resistant disease. 5
Itraconazole 200 mg daily for 5-7 days: Alternative effective regimen. 6, 2
Fluconazole 400 mg as a single dose: Highly effective single-dose option that can also be used prophylactically. 7, 6, 2
Fluconazole 50-100 mg daily for 2-3 weeks: Alternative dosing regimen. 6
Critical warning: Oral terbinafine is NOT effective for tinea versicolor and should not be used. 6, 2 Oral ketoconazole should no longer be prescribed due to hepatotoxicity risk. 4, 2
Advantages of Oral Therapy:
- Increased patient compliance and convenience 1
- Shorter treatment duration 1
- Reduced recurrence rates compared to topical therapy 1
Disadvantages of Oral Therapy:
Prevention of Recurrence
Long-term intermittent prophylactic therapy should be considered for patients with frequent recurrences. 1, 2
Follow-up should include both clinical and mycological assessment to document clearance. 5
Clean contaminated combs and brushes with disinfectant to prevent reinfection. 5
Consider prophylactic fluconazole 400 mg single dose periodically to prevent recurrence in susceptible patients. 7
Common Pitfalls
Do not use oral terbinafine - it is ineffective against Malassezia species despite being effective for other dermatophyte infections. 6, 2
Expect recurrences - tinea versicolor is chronically recurring due to Malassezia being part of normal skin flora, so counsel patients accordingly. 4, 1
Treatment failure may result from poor compliance, suboptimal medication absorption, or relative organism insensitivity. 8