Tinea versicolor (Pityriasis versicolor)
- Beth G Goldstein, MD
Beth G Goldstein, MD
- Adjunct Clinical Assistant Professor
- Department of Dermatology
- University of North Carolina at Chapel Hill
- Adam O Goldstein, MD, MPH
Adam O Goldstein, MD, MPH
- Department of Family Medicine
- University of North Carolina at Chapel Hill
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — Dermatology
- Professor of Dermatology
- Denver VA Medical Center, University of Colorado School of Medicine and Colorado School of Public Health
- Moise L Levy, MD
Moise L Levy, MD
- Section Editor — Pediatric Dermatology
- Clinical Professor of Dermatology and Pediatrics
- Baylor College of Medicine
- Professor of Pediatrics and Medicine
- Dell Medical School/University of Texas, Austin
- Ted Rosen, MD
Ted Rosen, MD
- Section Editor — Infections and Infestations
- Professor, Department of Dermatology
- Baylor College of Medicine
Tinea versicolor (ie, pityriasis versicolor) is a common superficial fungal infection. Patients with this disorder often present with hypopigmented, hyperpigmented, or erythematous macules on the trunk and proximal upper extremities (picture 1A-E). Unlike other disorders utilizing the term tinea (eg, tinea pedis, tinea capitis), tinea versicolor is not a dermatophyte infection. The causative organisms are saprophytic, lipid-dependent yeasts in the genus Malassezia (formerly known as Pityrosporum) .
Tinea versicolor responds well to medical therapy (table 1), but recurrence is common and long-term prophylactic therapy may be necessary. The clinical features, diagnosis, and management of tinea versicolor will be reviewed here.
Tinea versicolor occurs worldwide, but the highest incidence is found in tropical climates. Prevalence of up to 50 percent has been reported in some tropical countries . In Scandinavia, the prevalence has been estimated to be approximately 1 percent .
Tinea versicolor most commonly affects adolescents and young adults, but can also occur in children and has been reported in infants [3-6]. The disorder is not contagious, although successful inoculation has occurred under experimental conditions utilizing topical oils and occlusion [7,8].
PATHOGENESIS AND RISK FACTORS
Malassezia is a lipid-dependent, dimorphic fungus that is a component of normal skin flora. Transformation of Malassezia from yeast cells to a pathogenic mycelial form is associated with the development of clinical disease. External factors suspected of contributing to this conversion include exposure to hot and humid weather, hyperhidrosis, and the use of topical skin oils . Tinea versicolor is not related to poor hygiene.
- Gupta AK, Batra R, Bluhm R, Faergemann J. Pityriasis versicolor. Dermatol Clin 2003; 21:413.
- Gupta AK, Bluhm R, Summerbell R. Pityriasis versicolor. J Eur Acad Dermatol Venereol 2002; 16:19.
- Bouassida S, Boudaya S, Ghorbel R, et al. [Pityriasis versicolor in children: a retrospective study of 164 cases]. Ann Dermatol Venereol 1998; 125:581.
- Nanda A, Kaur S, Bhakoo ON, et al. Pityriasis (tinea) versicolor in infancy. Pediatr Dermatol 1988; 5:260.
- Jena DK, Sengupta S, Dwari BC, Ram MK. Pityriasis versicolor in the pediatric age group. Indian J Dermatol Venereol Leprol 2005; 71:259.
- Wyre HW Jr, Johnson WT. Neonatal pityriasis versicolor. Arch Dermatol 1981; 117:752.
- Faergemann J, Fredriksson T. Experimental infections in rabbits and humans with Pityrosporum orbiculare and P. ovale. J Invest Dermatol 1981; 77:314.
- BURKE RC. Tinea versicolor: susceptibility factors and experimental infection in human beings. J Invest Dermatol 1961; 36:389.
- Faergemann J. Pityriasis versicolor. Semin Dermatol 1993; 12:276.
- Hafez M, el-Shamy S. Genetic susceptibility in pityriasis versicolor. Dermatologica 1985; 171:86.
- He SM, Du WD, Yang S, et al. The genetic epidemiology of tinea versicolor in China. Mycoses 2008; 51:55.
- Güleç AT, Demirbilek M, Seçkin D, et al. Superficial fungal infections in 102 renal transplant recipients: a case-control study. J Am Acad Dermatol 2003; 49:187.
- Borelli D, Jacobs PH, Nall L. Tinea versicolor: epidemiologic, clinical, and therapeutic aspects. J Am Acad Dermatol 1991; 25:300.
- Morishita N, Sei Y. Microreview of Pityriasis versicolor and Malassezia species. Mycopathologia 2006; 162:373.
- Prohic A, Ozegovic L. Malassezia species isolated from lesional and non-lesional skin in patients with pityriasis versicolor. Mycoses 2007; 50:58.
- Karakaş M, Turaç-Biçer A, Ilkit M, et al. Epidemiology of pityriasis versicolor in Adana, Turkey. J Dermatol 2009; 36:377.
- Schwartz RA. Superficial fungal infections. Lancet 2004; 364:1173.
- Galadari I, el Komy M, Mousa A, et al. Tinea versicolor: histologic and ultrastructural investigation of pigmentary changes. Int J Dermatol 1992; 31:253.
- Nazzaro-Porro M, Passi S. Identification of tyrosinase inhibitors in cultures of Pityrosporum. J Invest Dermatol 1978; 71:205.
- Robertson LI. Itraconazole in the treatment of widespread tinea versicolor. Clin Exp Dermatol 1987; 12:178.
- Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: Pityriasis (tinea) versicolor. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol 1996; 34:287.
- Hu SW, Bigby M. Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010; 146:1132.
- Savin RC, Horwitz SN. Double-blind comparison of 2% ketoconazole cream and placebo in the treatment of tinea versicolor. J Am Acad Dermatol 1986; 15:500.
- Lange DS, Richards HM, Guarnieri J, et al. Ketoconazole 2% shampoo in the treatment of tinea versicolor: a multicenter, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol 1998; 39:944.
- Savin R, Eisen D, Fradin MS, Lebwohl M. Tinea versicolor treated with terbinafine 1% solution. Int J Dermatol 1999; 38:863.
- Vermeer BJ, Staats CC. The efficacy of a topical application of terbinafine 1% solution in subjects with pityriasis versicolor: a placebo-controlled study. Dermatology 1997; 194 Suppl 1:22.
- Treatment of tinea versicolor with a new antifungal agent, ciclopirox olamine cream 1%. Clin Ther 1985; 7:574.
- Sánchez JL, Torres VM. Double-blind efficacy study of selenium sulfide in tinea versicolor. J Am Acad Dermatol 1984; 11:235.
- Fredriksson T, Faergemann J. Double-blind comparison of a zinc pyrithione shampoo and its shampoo base in the treatment of tinea versicolor. Cutis 1983; 31:436.
- Leeming JP, Sansom JE, Burton JL. Susceptibility of Malassezia furfur subgroups to terbinafine. Br J Dermatol 1997; 137:764.
- Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg 2014; 18:79.
- Köse O, Bülent Taştan H, Riza Gür A, Kurumlu Z. Comparison of a single 400 mg dose versus a 7-day 200 mg daily dose of itraconazole in the treatment of tinea versicolor. J Dermatolog Treat 2002; 13:77.
- Partap R, Kaur I, Chakrabarti A, Kumar B. Single-dose fluconazole versus itraconazole in pityriasis versicolor. Dermatology 2004; 208:55.
- Karakaş M, Durdu M, Memişoğlu HR. Oral fluconazole in the treatment of tinea versicolor. J Dermatol 2005; 32:19.
- Amer MA. Fluconazole in the treatment of tinea versicolor. Egyptian Fluconazole Study Group. Int J Dermatol 1997; 36:940.
- Faergemann J. Treatment of pityriasis versicolor with a single dose of fluconazole. Acta Derm Venereol 1992; 72:74.
- Clayton YM, Connor BL. Comparison of clotrimazole cream, Whitfield's ointment and Nystatin ointment for the topical treatment of ringworm infections, pityriasis versicolor, erythrasma and candidiasis. Br J Dermatol 1973; 89:297.
- Clayton R, Du Vivier A, Savage M. Double-blind trial of 1% clotrimazole cream and Whitfield ointment in the treatment of pityriasis versicolor. Arch Dermatol 1977; 113:849.
- Bamford JT. Treatment of tinea versicolor with sulfur-salicylic shampoo. J Am Acad Dermatol 1983; 8:211.
- Faergemann J, Fredriksson T. Propylene glycol in the treatment of tinea versicolor. Acta Derm Venereol 1980; 60:92.
- Prestia AE. Topical benzoyl peroxide for the treatment of tinea versicolor. J Am Acad Dermatol 1983; 9:277.
- Hay RJ, Midgeley G. Short course ketoconazole therapy in pityriasis versicolor. Clin Exp Dermatol 1984; 9:571.
- Zaias N. Pityriasis versicolor with ketoconazole. J Am Acad Dermatol 1989; 20:703.
- Goodless DR, Ramos-Caro FA, Flowers FP. Ketoconazole in the treatment of pityriasis versicolor: international review of clinical trials. DICP 1991; 25:395.
- www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2013/07/news_detail_001855.jsp&mid=WC0b01ac058004d5c1 (Accessed on July 26, 2013).
- www.fda.gov/Drugs/DrugSafety/ucm362415.htm (Accessed on July 26, 2013).
- www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm502073.htm (Accessed on May 23, 2016).
- Faergemann J, Todd G, Pather S, et al. A double-blind, randomized, placebo-controlled, dose-finding study of oral pramiconazole in the treatment of pityriasis versicolor. J Am Acad Dermatol 2009; 61:971.
- Faergemann J, Gupta AK, Al Mofadi A, et al. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol 2002; 138:69.
- Rausch LJ, Jacobs PH. Tinea versicolor: treatment and prophylaxis with monthly administration of ketoconazole. Cutis 1984; 34:470.
- PATHOGENESIS AND RISK FACTORS
- CLINICAL FEATURES
- DIFFERENTIAL DIAGNOSIS
- Patient education
- First-line therapy
- - Topical antifungals
- - Selenium sulfide
- - Zinc pyrithione
- Severe or recalcitrant disease
- - Oral therapies
- Other therapies
- Treatment failure
- Emerging therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS