What is the best treatment for Pityriasis (Pityriasis versicolor)?

Treatment for Pityriasis Versicolor

For pityriasis versicolor, start with topical ketoconazole 2% cream applied once daily for 2 weeks, which is FDA-approved and highly effective for this superficial Malassezia infection. 1

First-Line Topical Treatment

Topical antifungal medications are the first-line treatment for pityriasis versicolor. 2 The FDA-approved regimen is:

• Ketoconazole 2% cream applied once daily to affected areas and immediate surrounding skin for 2 weeks 1
• The cream should cover both the visible lesions and the surrounding area to address subclinical infection 1
• Clinical improvement may be seen early, but the full 2-week course is necessary to reduce recurrence 1

Alternative Topical Options

If ketoconazole cream is unavailable or not tolerated, other effective topical agents include:

• Ketoconazole shampoo (applied to affected areas, left on briefly, then rinsed) 2, 3
• Zinc pyrithione shampoo 2, 3
• Selenium sulfide preparations 3, 4
• Terbinafine cream 2

These alternatives have comparable efficacy to ketoconazole, though keratolytic agents like selenium sulfide may cause more irritation (acute dermatitis reported in some patients) 4

Systemic Treatment for Severe or Recalcitrant Cases

For extensive disease or treatment failures, oral antifungals are appropriate: 2, 5

• Fluconazole 400 mg as a single oral dose is highly effective and well-tolerated 2, 6
• Itraconazole 400 mg as a single oral dose is an alternative, though fluconazole shows superior efficacy (65% vs 20% culture negativity at 8 weeks) and lower relapse rates (35% vs 60%) 6
• Oral terbinafine is NOT effective for pityriasis versicolor and should not be used 2
• Oral ketoconazole should no longer be prescribed due to safety concerns 2

Critical Management Considerations

Recurrence Prevention

Pityriasis versicolor has high recurrence rates because Malassezia is part of normal skin flora. 2, 3 To minimize relapse:

• Consider prophylactic maintenance therapy with periodic application of topical antifungals 2
• Treat perilesional skin, as positive cultures from surrounding normal-appearing skin correlate directly with relapse 6
• Address predisposing factors: high humidity environments, hyperhidrosis, greasy skin, corticosteroid use 3

Common Pitfalls to Avoid

• Do not stop treatment early - even if clinical improvement appears within days, complete the full 2-week course to prevent recurrence 1
• Do not use oral terbinafine - it is ineffective against Malassezia species despite being effective for dermatophyte infections 2
• Do not prescribe oral ketoconazole - hepatotoxicity risks outweigh benefits when safer alternatives exist 2
• Warn patients about repigmentation timing - the hypopigmented or hyperpigmented patches may take weeks to months to normalize even after successful fungal eradication 3

Diagnostic Confirmation

Wood's lamp examination can aid diagnosis, showing characteristic yellow-green fluorescence 7, though clinical diagnosis is usually straightforward with the typical fine scale on hypopigmented or hyperpigmented macules 7, 3