What is the recommended treatment regimen for pityriasis (tinea) versicolor?

Treatment of Pityriasis Versicolor

For pityriasis versicolor, topical ketoconazole 2% cream applied once daily for 2 weeks is the first-line treatment, with oral azoles (itraconazole or fluconazole) reserved for extensive, recalcitrant, or recurrent disease. 1

First-Line Topical Therapy

Topical antifungals are the primary treatment approach for most cases of pityriasis versicolor. 2

• Ketoconazole 2% cream applied once daily for 2 weeks is the FDA-approved regimen and should be applied to cover the affected area and immediate surrounding skin 1
• Alternative topical options include zinc pyrithione shampoo or terbinafine cream, though ketoconazole has the strongest evidence base 2
• Clotrimazole 1% cream applied twice daily for 2-4 weeks is another effective option, with 85% cure rates comparable to ketoconazole 3
• Clinical improvement may appear early, but the full 2-week course is essential to reduce recurrence risk 1

Oral Therapy for Extensive or Recalcitrant Disease

When topical therapy fails or disease is widespread, systemic antifungals are highly effective. 2, 4

• Fluconazole 400 mg as a single dose is an excellent option with high cure rates 4, 5
• Itraconazole 200 mg daily for 5-7 days is equally effective 4, 6
• These oral regimens are particularly useful when patient adherence to topical therapy is poor or when the infection covers large body surface areas 2

Critical Caveat: Avoid Oral Terbinafine and Ketoconazole

• Oral terbinafine is ineffective for pityriasis versicolor and should not be prescribed 2, 4
• Oral ketoconazole should no longer be used due to hepatotoxicity risk, despite historical use 5

Prophylactic Therapy for Recurrent Infections

Recurrence is extremely common with pityriasis versicolor because Malassezia is part of normal skin flora. 2, 6

• Maintenance therapy with ketoconazole 2% shampoo or cream applied once weekly or monthly can prevent recurrence 6
• Prophylactic regimens are particularly important in tropical climates or patients with predisposing factors (hyperhidrosis, greasy skin, high humidity exposure) 6
• Limited research exists on optimal prophylactic protocols, but clinical experience supports intermittent topical antifungal use 2

Treatment Monitoring

• Mycological cure, not just clinical clearing, should be the treatment endpoint 2
• Hypopigmentation or hyperpigmentation may persist for weeks to months after successful fungal eradication and does not indicate treatment failure 2
• If lesions persist after completing the recommended treatment duration, consider extending therapy or switching to oral agents 1

Practical Algorithm

1. Localized disease (< 20% body surface area): Start with topical ketoconazole 2% cream once daily for 2 weeks 1
2. Extensive disease or topical treatment failure: Use fluconazole 400 mg single dose OR itraconazole 200 mg daily for 5-7 days 4
3. Recurrent infections (≥ 2 episodes per year): Implement prophylactic ketoconazole 2% shampoo weekly to monthly 6
4. Never use oral terbinafine or oral ketoconazole 2, 5