What is the treatment for Tinea versicolor?

Treatment of Tinea Versicolor

For tinea versicolor, topical ketoconazole 2% cream applied once daily for 2 weeks is the first-line treatment, with oral azole antifungals (ketoconazole 400 mg single dose or fluconazole 150-400 mg) reserved for extensive disease or treatment failures. 1

Topical Therapy (First-Line)

Ketoconazole 2% cream is FDA-approved and should be applied once daily to affected areas and immediate surrounding skin for 2 weeks. 1 This regimen achieves high cure rates with minimal side effects. 2

Alternative Topical Options:

• Ketoconazole 2% shampoo can be used as a single application or daily for 3 consecutive days, with clinical response rates of 69-73% at 31 days—both regimens are equally effective. 3 The shampoo formulation is particularly useful for large body surface areas where cream application is impractical. 2
• Selenium sulfide is effective but associated with higher recurrence rates compared to azole antifungals. 2

Oral Therapy (For Extensive Disease or Treatment Failures)

When topical therapy fails or disease is too extensive for practical topical application, oral azole antifungals are highly effective:

Dosing Regimens:

• Fluconazole: 400 mg as a single dose, or 150 mg once weekly for 2 weeks. 4, 5 Both regimens demonstrate excellent efficacy with maximal cure rates at 8 weeks. 5
• Ketoconazole: 400 mg as a single dose (can be repeated weekly for 2 weeks). 4, 5, 6 This has been used successfully for years, though carries a low risk of hepatotoxicity. 2
• Itraconazole: 200 mg daily for 5-7 days. 4

Terbinafine is ineffective for tinea versicolor and should not be used. 4 This is critical because terbinafine is highly effective for other tinea infections but does not work against Malassezia furfur, the causative organism. 2

Treatment Monitoring and Expected Outcomes

• Clinical improvement occurs fairly soon after treatment begins, but the full 2-week course should be completed to reduce recurrence risk. 1
• Hypopigmentation may persist for months after mycological cure—this does not indicate treatment failure. 5 Wood's lamp examination can help detect mycological cure even when pigmentary changes remain. 5
• Recurrence is common regardless of treatment modality, particularly in tropical climates and during warm seasons. 2, 6

Prevention of Recurrence

• Prophylactic oral ketoconazole 400 mg as a single dose can be used periodically in patients with frequent recurrences. 6
• Environmental factors (heat, humidity, sweating) predispose to recurrence—patients should be counseled that complete prevention is often not achievable. 6

Critical Pitfalls to Avoid

• Do not use terbinafine—it is completely ineffective against Malassezia furfur despite being excellent for dermatophyte infections. 4
• Do not discontinue treatment prematurely based on clinical appearance alone—complete the 2-week topical course or prescribed oral regimen. 1
• Do not confuse persistent hypopigmentation with treatment failure—repigmentation lags behind mycological cure by weeks to months. 5
• Ketoconazole carries hepatotoxicity risk (though low)—consider this when selecting oral therapy, particularly for prophylactic use. 2