What is the treatment for pityriasis (versicolor)?

Treatment of Pityriasis Versicolor

For pityriasis versicolor, topical selenium sulfide 2.5% applied daily for 7 days is the first-line treatment for limited disease, while oral fluconazole or itraconazole should be used for extensive involvement (>25% body surface area). 1, 2

Topical Treatment Options

First-Line Topical Therapy

• Selenium sulfide 2.5% shampoo is highly effective and FDA-approved: apply to affected areas, lather with small amount of water, leave on skin for 10 minutes, then rinse thoroughly once daily for 7 days 1
• Remove jewelry before application as the product may cause damage 1
• Wash hands thoroughly after treatment 1

Alternative Topical Agents

• Ketoconazole 2% shampoo once weekly for 3 weeks achieves 95% cure rates and is comparable to selenium sulfide 3
• Other effective topical options include zinc pyrithione shampoo, ciclopiroxolamine, propylene glycol 50%, and topical imidazoles 2, 4
• Ketoconazole 2% foam applied twice weekly can be used as monotherapy or in combination regimens 5

Systemic Treatment for Extensive Disease

When to Use Oral Therapy

• Systemic antifungals are indicated when body surface area involvement exceeds 25% 6
• Oral therapy offers superior patient compliance and effectiveness compared to topical treatment in extensive cases 4

Oral Treatment Regimens

• Fluconazole 300 mg weekly for 2 weeks combined with ketoconazole 2% foam twice weekly achieves the highest cure rate (62.4%) 5
• Itraconazole 200 mg daily for 7 days is effective and well-tolerated for short-term use 2, 4
• Ketoconazole 400 mg single dose achieves 87.9% improvement but carries hepatotoxicity concerns 6
• Fluconazole is preferred over ketoconazole for systemic therapy due to better safety profile despite similar efficacy 6

Prophylaxis and Recurrence Prevention

Critical Consideration

• Prophylactic treatment is mandatory to prevent recurrence, which occurs at very high rates without maintenance therapy 2, 4

Prophylactic Regimens

• Ketoconazole 200 mg for 3 consecutive days every month prevents recurrence 4
• Alternative: ketoconazole 400 mg single dose monthly 4
• Selenium sulfide or ketoconazole shampoo can be used intermittently for long-term suppression 2

Treatment Selection Algorithm

1. Limited disease (<25% BSA): Start with selenium sulfide 2.5% daily for 7 days or ketoconazole 2% shampoo weekly for 3 weeks 1, 3

2. Extensive disease (≥25% BSA): Use fluconazole 300 mg weekly for 2 weeks combined with ketoconazole 2% foam twice weekly 5

3. Difficult or recalcitrant cases: Short-term oral itraconazole 200 mg daily for 7 days 2, 4

4. All patients: Implement prophylactic regimen after initial cure to prevent recurrence 2, 4

Common Pitfalls to Avoid

• Failing to implement prophylaxis leads to rapid recurrence due to persistent predisposing factors (heat, humidity, hyperhidrosis, genetic susceptibility) 2, 4
• Using ketoconazole systemically without considering hepatotoxicity risk, particularly when fluconazole offers similar efficacy with better safety 6
• Inadequate contact time with topical agents—selenium sulfide requires full 10 minutes on skin for effectiveness 1
• Not addressing jewelry removal before selenium sulfide application can result in jewelry damage 1

Follow-Up Assessment

• Clinical and mycological assessment should occur 4 weeks after treatment completion 5
• Monitor for relapse during 3-month follow-up period, which occurs in 5-10% of adequately treated patients 3