Treatment of Pityriasis Versicolor Caused by Malassezia Species
For pityriasis versicolor caused by Malassezia species, topical ketoconazole 2% cream or selenium sulfide lotion are the first-line treatments, with ketoconazole applied once daily to affected areas and selenium sulfide applied for 10 minutes daily for 7 days. 1, 2
First-Line Topical Therapy
Ketoconazole 2% Cream
- Apply once daily to affected areas until clinical clearing is achieved 1
- FDA-approved specifically for tinea (pityriasis) versicolor caused by Malassezia furfur (Pityrosporum orbiculare) 1
- Effective against the mycelial form of Malassezia that causes the characteristic lesions 3
Selenium Sulfide Lotion
- Apply to affected areas, lather with small amount of water, leave on skin for 10 minutes, then rinse thoroughly 2
- Repeat once daily for 7 days 2
- This is a complete treatment course with defined duration 2
Causative Organisms
The disease is caused by Malassezia yeasts, with M. globosa being the predominant species (found in 97.3% of cases in molecular studies), not M. furfur as historically believed 4. M. furfur accounts for approximately 34% of isolates when cultured 5. The pathogenic mycelial form of these yeasts causes the characteristic scaly hypopigmented or hyperpigmented lesions 3, 6.
Clinical Considerations
Hypopigmentation Management
- Hypopigmented lesions persist after successful antifungal treatment because the fungal metabolites have already affected melanin synthesis 7
- Rapid initiation of antimycotic therapy followed by ultraviolet light exposure can help accelerate repigmentation by inducing maturation of existing melanosomes 7
- However, depigmented lesions remain difficult to improve even with UV therapy 7
Common Pitfalls
- Do not delay treatment - the longer the infection persists, the more difficult hypopigmentation becomes to reverse 7
- Recurrence is common (up to 60% of patients) even after effective initial treatment 3
- The disease tends to recur because Malassezia species are normal skin saprophytes that convert to pathogenic mycelial forms under certain endogenous and exogenous conditions 6
Alternative Systemic Options
While not detailed in the FDA labels provided, oral azole antifungals (fluconazole, itraconazole) are mentioned in clinical literature as alternatives for extensive disease or recurrent cases 3. However, topical therapy should be attempted first given the superficial nature of the infection and excellent safety profile of topical agents 3.