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Tinea Versicolor

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Ovid: 5-Minute Sports Medicine Consult, The


Tinea Versicolor
Mark Sakr
Jeffrey R. Bytomski
Basics
Description
  • Tinea versicolor, also known as pityriasis versicolor, is a common superficial skin infection that is caused by the lipophilic yeast Pityrosporum.
    • Pityrosporum is found in the normal skin flora. The primary species in tinea versicolor is Pityriasis ovale (formerly named Malassezia furfur) (1).
  • Hot and humid weather, excessive sweating, use of oils, and immunosuppression can cause the transformation from the benign yeast spores to the hyphal form that causes clinical disease.
  • Skin lesions manifest as hypo/hyperpigmentation or light pink/salmon, brown, or white colored patches. They occur primarily on the upper extremities and trunk, less frequently on the face and intertriginous areas (2).
  • The lesions are often small macules but can coalesce into larger papules. The lesions have a fine scaly appearance and may be mildly pruritic.
  • Synonym(s): Sun spots; Pityriasis versicolor
Epidemiology
Disease may occur at any age but is much more common during the years of higher sebaceous activity (ie, adolescence and young adulthood).
Incidence
  • ∼2–8% of the population
  • The exact incidence in the U.S. is difficult to assess because many individuals who are affected may not seek medical attention.
Prevalence
  • 40% prevalence in tropical areas (2)
  • Occurs worldwide, with prevalences reported to be as high as 50% in the humid, hot environment of western Samoa and as low as 1.1% in the colder temperatures of Sweden
  • 3% of all dermatologist visits during the summer months in temperate areas (2)
  • 90–100% of adults are colonized (2).
  • Occurs most commonly during adolescence and young adulthood but is seen in childhood as well.
  • Adults who present with this disease are likely to suffer from recurrent episodes from early adulthood.
  • Most commonly seen in the summer months, when patients perspire more and sun exposure leads to skin color changes that highlight the lesions
Risk Factors
  • Excess heat and humidity
  • Adrenalectomy
  • Cushing disease
  • Pregnancy
  • Malnutrition
  • Burns
  • Corticosteroid therapy
  • Immunosuppression
  • Oral contraceptives
  • Individuals with oily skin
  • Diabetes mellitus
General Prevention
  • Avoid using oil or oily products on the skin.
  • Avoid constrictive or unvented clothing in warm weather.
  • Prophylactic topical or oral antifungal therapy in patients with recurrent lesions (2)
Etiology
  • The discoloration is secondary to damage of the melanocytes and the body's inflammatory response to the yeast.
  • Tinea versicolor is not contagious.
Commonly Associated Conditions
  • Diabetes mellitus
  • Immunosuppression
  • HIV
  • Chronic corticosteroid use
  • Cushing disease
  • Hyperhidrosis
  • Pregnancy
  • Oral contraceptives
  • Malnutrition
  • Adrenalectomy
Diagnosis
History
  • The lesions are usually asymptomatic, but they may be pruritic.
  • Patients may present with areas of skin that do not tan with sun exposure.
  • Older patients will sometimes have a history of similar skin lesions since early adolescence.
Physical Exam
  • Multiple small circular macules of various colors that enlarge radially
  • Lesions may be hyper- or hypopigmented; the color is uniform in each individual.
  • The upper trunk is most commonly involved, but lesions may spread to the upper arms, neck, face, and abdomen.
Diagnostic Tests & Interpretation
Diagnostic Procedures/Surgery
  • An overlying powdery scale can be easily removed with a number 15 surgical blade or transparent tape. The scale is then evaluated by direct microscopy.
  • Wood's light examination shows irregular yellow to white fluorescence; some lesions may not fluoresce.
Pathological Findings
  • Direct microscopic examination of skin scrapings in 10% potassium hydroxide (KOH)
  • Classic pattern of “spaghetti and meatballs” of yeast hyphae and spores (1)
  • Skin biopsy yielding stratum corneum with abundant short hyphae and round budding cellular fungal elements is also diagnostic, but this is an invasive means of diagnosis.
Differential Diagnosis
  • Vitiligo
  • Psoriasis
  • Pityriasis rosea
  • Pityriasis alba
  • Seborrheic dermatitis
  • Secondary syphilis
  • Tinea corporis

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Treatment
Medication
First Line
Topical therapy:
  • Selenium sulfide lotion/shampoo 2.5% applied to the skin for 10–15 min a day for 7–14 days
  • Alternately, apply lotion to affected area for 24 hr before washing off, repeating weekly for 4 wks.
  • Ketoconazole 2% shampoo applied 1 time or daily for 3 days is also effective (69% cure rate) (3).
  • Miconazole, clotrimazole, ketoconazole, econazole, or ciclopirox lotions can be applied to affected area twice daily for 2–4 wks (∼76–100% cure rates for these therapies) (3).
Second Line
Systemic therapy:
  • Fluconazole 400 mg is effective as a single oral dose (80% cure rate) (1).
  • Itraconazole 200 mg/day PO for 5 days (92% cure rate) (3)
  • Ketoconazole may be given as a single 400-mg dose or in as 200 mg/day for 5 days (∼77% cure rate) (4).
  • Systemic treatments may be given to patients who fail topical therapies. Caution is advised with the use of oral antifungals in patients with liver disease.
Additional Treatment
  • Selenium sulfide 2.5% shampoo applied to affected areas on the 1st and 3rd days of each month for 6 mos is a topical prophylactic therapy (2).
  • Itraconazole 200 mg PO administered twice a day for 1 day each month is an effective oral prophylactic treatment (3).
  • Ketoconazole 400 mg PO once a month or 200 mg for 3 consecutive days at the beginning of each month is an alternate treatment (2).
General Measures
  • Keep skin dry and clean during warm seasons.
  • Avoid using oily products on the skin.
  • Avoid constrictive or unvented clothing in warm weather.
  • Wash skin immediately after exercise and accumulation of sweat.
Referral
  • Unclear diagnosis
  • Failure to respond to therapy
  • Resistance to treatment may point to other underlying medical conditions that deserve proper evaluation.
Ongoing Care
  • Repeat above treatments as necessary.
  • If patient has multiple recurrences and requires systemic treatments each time, check baseline liver function tests (especially with ketoconazole).
Follow-Up Recommendations
Patient Monitoring
  • Skin color does not reverse immediately.
  • Return to normal pigmentation takes 1–2 mos on average with adequate treatment.
  • The inability to produce a powdery scale with a number 15 surgical blade or transparent tape indicates that the fungus has been eliminated.
  • Recurrence rates are high, estimated at 40–60% in the 1st yr and up to 80% in the 2nd yr (2).
  • Exposure to sunlight will help to accelerate repigmentation when hypopigmented lesions predominate.
  • Re-evaluate for treatment each spring, prior to prolonged outdoor activities or tanning season.
Prognosis
  • Treatments have high success rates, but recurrences are common.
  • Lesions may last for months.
References
1. Usatine RP. Variations in color. J Fam Pract. 2003;52:481–484.
2. Schwartz RA. Superficial fungal infections. Lancet. 2004;364:1173–1182.
3. Faergemann J, Gupta AK, Al Mofadi A, et al. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol. 2002;138:69–73.
4. Kose O, Bülent Taştan H, Riza Gür A, et al. Comparison of a single 400 mg dose versus a 7-day 200 mg daily dose of itraconazole in the treatment of tinea versicolor. J Dermatol. Treat. 2002;13:77–79.
Additional Reading
Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev. 2007;CD001434
Stulberg DL, Clark N, Tovey D. Common hyperpigmentation disorders in adults: Part II. Melanoma, seborrheic keratoses, acanthosis nigricans, melasma, diabetic dermopathy, tinea versicolor, and postinflammatory hyperpigmentation. Am Fam Physician. 2003;68:1963–1968.
Codes
ICD9
111.0 Pityriasis versicolor
Clinical Pearls
  • Skin lesions manifest as hypo/hyperpigmentation or light pink/salmon, brown, or white colored patches.
  • Occur primarily on the upper extremities and trunk, less frequently on the face and intertriginous areas
  • The lesions are often small macules but can coalesce into larger papules.
  • Fine scaly appearance
  • May be mildly pruritic
  • Most commonly seen in the summer months, when patients perspire more and sun exposure leads to skin color changes that highlight the lesions
  • Classic pattern of “spaghetti and meatballs” of yeast hyphae and spores on direct microscopy
  • Mainstay of treatment involves topical or systemic antifungals.
  • Recurrence rates are high.


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