INTRODUCTION — 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) [1].
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.
EPIDEMIOLOGY — 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 [2]. In Scandinavia, the prevalence has been estimated to be approximately 1 percent [2].
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 [9]. Tinea versicolor is not related to poor hygiene.
Host characteristics that contribute to the development of tinea versicolor are poorly understood. A genetic predisposition may be involved [10]. In a questionnaire-based study, 21 percent of patients reported a positive family history of the disease [11]. Tinea versicolor also occurs more commonly in patients who are immunosuppressed, suggesting that an altered host immune response may play a role in the pathogenesis [12]. Oral contraceptive therapy and malnutrition may be additional predisposing factors [13].
M. globosa appears to be the predominant causal species in tinea versicolor [14-16]. M. sympodialis, M. furfur, and other Malassezia species have also been implicated [17]. (See "Invasive Malassezia infections".)
CLINICAL FEATURES — The term "versicolor" refers to the variable changes in cutaneous pigmentation that may occur in this disorder. The macules, patches, and thin plaques of tinea versicolor can be hypopigmented, hyperpigmented, or mildly erythematous (picture 1A-E). In light-skinned individuals, hyperpigmented tinea versicolor is often light brown. Hyperpigmented tinea versicolor may present as dark brown to gray-black macules and patches in those with dark skin (picture 2).
The color of affected areas can vary between individuals with similar skin color, and occasionally, between areas of involvement on one person. Although the reasons for pigmentary variation are unconfirmed, a few theories have been proposed. Patients with hypopigmented tinea versicolor often notice that the disorder is most prominent during the summer, when the affected areas fail to tan after sun exposure. Inhibitory or damaging effects on melanocytes by azelaic acid (a dicarboxylic acid produced by Malassezia) may play a role in the development of hypopigmentation [18,19]. Hyperpigmented and erythematous lesions may be a consequence of an inflammatory reaction to the yeast [18].
A fine scale is often present on affected skin, which becomes more apparent when the lesion is scraped for microscopy. Individual lesions are typically small, but frequently coalesce into larger patches. In adolescents and adults, tinea versicolor is most commonly found on the upper trunk and proximal upper extremities, and less often on the face and intertriginous areas. In contrast, when tinea versicolor occurs in children, it is likely to involve the face (picture 3A-B) [1,3].
The distribution of tinea versicolor on the body may reflect the nutritional requirements of the yeast. Malassezia is lipid-dependent, and the greater sebum production by cutaneous sebaceous glands on the upper body may contribute to the predominance of tinea versicolor in this location. This theory may also account for the less frequent occurrence of this disorder in children and older adults, in whom sebum production is lower [1,2].
While most patients are asymptomatic, some complain of mild pruritus, and many are concerned about cosmesis. Although spontaneous remission has been reported [20], the disorder can be persistent if untreated.
Data on dermoscopic findings of tinea versicolor are limited. Frequent dermoscopic findings appear to be nonuniform pigmentation within lesions, fine scale, and perilesional hyperpigmentation or hypopigmentation [21-23]. Other features have also been reported [21-23].
DIAGNOSIS — A diagnosis of tinea versicolor should be suspected when a patient presents with hypopigmented or hyperpigmented macules coalescing into patches on the upper trunk, proximal extremities, neck, or face. The variable clinical features of tinea versicolor and the existence of other skin disorders with similar findings make it preferable to confirm the diagnosis with a potassium hydroxide (KOH) preparation. Both hyphae and yeast cells are evident in a pattern that is often described as "spaghetti and meatballs" (picture 4). Additionally, in approximately one-third of cases, examination with a Wood's lamp will reveal yellow to yellow-green fluorescence [17]. (See "Office-based dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation'.)
DIFFERENTIAL DIAGNOSIS — The differential diagnosis of tinea versicolor consists of several common and uncommon skin disorders. The potassium hydroxide (KOH) preparation is a simple and reliable way to confirm the diagnosis. Examples of skin disorders that may resemble tinea versicolor include:
●Seborrheic dermatitis – Seborrheic dermatitis on the trunk is usually more erythematous than tinea versicolor, and typically has thicker scale. Patients often exhibit other areas of involvement such as the scalp, eyebrows, and nasolabial folds (picture 5). (See "Overview of dermatitis (eczematous dermatoses)", section on 'Seborrheic dermatitis' and "Seborrheic dermatitis in adolescents and adults", section on 'Clinical manifestations'.)
●Pityriasis rosea – Patients with classic pityriasis rosea present with inflammatory macules and small patches in a "Christmas tree-like" distribution on the trunk. A larger herald patch that precedes the widespread eruption is often noted. Lesions are erythematous and exhibit a collarette of scale (picture 6). In dark-skinned individuals, hyperpigmentation can be prominent (picture 7). (See "Pityriasis rosea".)
●Vitiligo – Vitiligo is characterized by completely depigmented macules and patches (picture 8). In contrast, tinea versicolor exhibits hypopigmented skin lesions. (See "Vitiligo: Pathogenesis, clinical features, and diagnosis".)
●Erythrasma – Erythrasma may present with erythematous or hyperpigmented patches in the axillae or groin, and is included in the differential diagnosis of intertriginous tinea versicolor (picture 9A-B). Sites of erythrasma exhibit coral-red fluorescence upon illumination with a Wood's lamp (picture 10). (See "Erythrasma".)
●Pityriasis alba – Pityriasis alba is a mild form of eczematous dermatitis that presents with hypopigmented macules and small patches on the face, and less frequently on the upper extremities (picture 11A-B). Fine scale may be visible. The disorder is most common in children with an atopic history. (See "Acquired hypopigmentation disorders other than vitiligo", section on 'Pityriasis alba'.)
●Secondary syphilis – Patients with secondary syphilis may present with erythematous to brown macules, papules, or small plaques in a generalized distribution (picture 12). Skin involvement is often present on the palms and soles (picture 13). (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Clinical manifestations'.)
●Confluent and reticulated papillomatosis of Gougerot and Carteaud – This uncommon cutaneous disorder usually occurs in young adults. Hyperpigmented, scaly patches with a reticulated appearance are present (picture 14A-D). The neck, chest (particularly intermammary area), and upper back may be affected.
●Mycosis fungoides – Mycosis fungoides may present as hypopigmented patches on the skin, with a predilection for the trunk and extremities (picture 15). This variant of the disorder occurs most commonly in individuals with dark skin. Fine scale, erythema, or infiltrated plaques may also be present. (See "Clinical manifestations, pathologic features, and diagnosis of mycosis fungoides".)
●Terra firma-forme dermatosis – Terra firma-forme dermatosis is a benign condition in which retention hyperkeratosis leads to the appearance of hyperpigmented papules or plaques that can resemble dirty skin (picture 16A-B) [24]. Common locations are the neck and ankle. In contrast to tinea versicolor, lesions are easily removed with an alcohol swab. (See "Acquired hyperpigmentation disorders", section on 'Terra firma-forme dermatosis'.)
TREATMENT — Topical therapy is the treatment of choice for patients with tinea versicolor. Systemic therapy is typically reserved for patients with widespread or recurrent tinea versicolor, or for patients who have failed topical therapy (table 1) [25].
High-quality comparative studies on the relative efficacy of specific treatments for tinea versicolor are limited, making the optimal approach to treatment unclear. A systematic review and meta-analysis of controlled trials found that most trials that compared treatment regimens or therapeutic agents were underpowered to detect meaningful differences [26]. The results suggested that longer courses of treatment, higher concentrations of topical active ingredients, and higher doses of oral antifungals may improve cure rates; however additional studies are necessary to confirm this conclusion. A table listing common treatment regimens for tinea versicolor is provided (table 1).
Patient education — Prior to treatment, patients should be advised that changes in cutaneous pigment often persist after successful treatment. Restoration of normal pigmentation may take months after the completion of successful therapy. (See 'Treatment failure' below.)
First-line therapy — Topical antifungal medications, topical selenium sulfide, and topical zinc pyrithione are effective and well-tolerated first-line therapies for tinea versicolor (table 1) [26].
Topical antifungals — Topical azole antifungals, topical terbinafine, and topical ciclopirox improve tinea versicolor via direct antifungal activity. Effective treatment regimens ranging from a few days to four weeks in length are reported in the literature [26]:
●Azole antifungals – Small randomized trials support the efficacy of various topical azole antifungals (table 2) [26]. In one randomized trial, ketoconazole 2% cream applied once daily for 11 to 22 days (mean 14 days) was superior to placebo (84 versus 22 percent achieved mycologic cure) [27]. A typical course of treatment with a topical azole antifungal is daily application for two weeks.
The shampoo formulation of ketoconazole appears to be effective with a shorter duration of therapy. The shampoo is applied to affected areas and is washed off after five minutes. In a randomized trial, a single application of ketoconazole 2% shampoo was compared with treatment on three consecutive days. Both regimens resulted in mycologic cure in approximately 80 percent of patients [28].
In accordance with the trial results, we consider both the three-day and one-day regimens for ketoconazole shampoo reasonable approaches to treatment. However, given the common location of tinea versicolor in skin sites that are difficult for patients to see and reach, the potential for environmental or patient-specific factors to influence the efficacy of treatment, and the minimal risks of treatment, we typically advise patients to treat for three consecutive days in an attempt to increase the likelihood of adequate treatment.
●Terbinafine – Topical terbinafine 1% solution applied twice daily for one week has been proven effective in small randomized trials [29,30].
●Ciclopirox – Topical ciclopirox olamine 1% cream was effective in two small randomized trials when applied twice daily for 14 days [31].
Selenium sulfide — Topical selenium sulfide exerts antifungal activity primarily through the promotion of shedding of the infected stratum corneum. In a randomized trial, application of selenium sulfide 2.5% lotion for 10 minutes for seven days was superior to placebo in achieving mycologic cure (81 versus 15 percent cured, respectively) [32].
The shampoo formulation of selenium sulfide 2.5% is often prescribed in clinical practice. Patients apply the shampoo to the affected area daily for one week. The shampoo is rinsed off after 10 minutes.
A non-prescription selenium sulfide 1% shampoo is also available, but the efficacy of this product for the treatment of tinea versicolor has not been studied.
Zinc pyrithione — In a controlled trial that included 40 patients with tinea versicolor, zinc pyrithione 1% shampoo applied for five minutes per day for two weeks was more effective than placebo for the treatment of tinea versicolor [33]. All patients treated with zinc pyrithione shampoo were successfully treated compared with none of the patients in the placebo group.
Severe or recalcitrant disease — Oral therapy is reserved for patients with tinea versicolor that is refractory to topical therapy or widespread disease that makes the application of topical drugs difficult [1,25]. It is important to note that persistent dyspigmentation is not a good indicator of failure of topical therapy. (See 'Treatment failure' below.)
Oral therapies — Oral azole antifungals such as itraconazole and fluconazole are effective for the treatment of tinea versicolor (table 1). In contrast to topical terbinafine, oral terbinafine is not effective [34]. Similarly, griseofulvin cannot be used for this condition.
Systemic therapy is not used as a first-line treatment for limited tinea versicolor to minimize risk of adverse effects. Abnormalities in liver function tests and drug interactions can occur with systemic azole antifungals. (See "Pharmacology of azoles", section on 'Adverse effects' and "Pharmacology of azoles", section on 'Drug interactions'.)
Oral therapy is not typically used for the treatment of tinea versicolor in children.
Itraconazole — Itraconazole therapy for tinea versicolor in adults is usually given as 200 mg per day for five days. Multiple randomized trials have reported mycologic cure rates between 70 and 100 percent with 200 mg of itraconazole daily for seven days, and dose comparison studies have shown similar success with treatment durations of five days [35].
Data conflict on the efficacy of a single 400 mg dose of itraconazole. In a randomized, open-label trial, a single 400 mg dose was as effective as 200 mg daily for seven days [36]. However, a low rate of response to a single 400 mg dose of itraconazole was reported in a trial that compared single-dose fluconazole and single-dose itraconazole [37].
Fluconazole — Fluconazole for tinea versicolor in adults is typically given as a 300 mg dose once weekly for two weeks [35]. In a small, uncontrolled study, 300 mg once weekly for two weeks led to mycologic and clinical cure in 75 percent of patients with tinea versicolor [38]. A dose-finding randomized trial also supports the efficacy of this regimen; 300 mg once weekly for up to two weeks resulted in mycologic cure in 87 percent of patients [39].
A single dose of fluconazole may be effective. In an uncontrolled study of 24 individuals with extensive or recurrent tinea versicolor treated with a single 400 mg dose of fluconazole, resolution of clinical disease occurred in 74 percent [40].
Other therapies — Additional topical and systemic therapies have been used for the treatment of tinea versicolor:
●Topical agents – Whitfield ointment [41,42] and sulfur-salicylic acid shampoo [43] are effective for tinea versicolor, but may cause skin irritation in a minority of patients. Small uncontrolled studies suggest that propylene glycol [44] and benzoyl peroxide [45] may also improve tinea versicolor.
●Oral ketoconazole – Although oral ketoconazole was effective for tinea versicolor in small randomized trials [46,47], life-threatening hepatotoxicity and adrenal insufficiency, along with multiple potential drug-drug interactions, have been reported with oral ketoconazole therapy, making it an unfavorable choice for the treatment of tinea versicolor. Although these adverse effects appear to be rare with the short duration of therapy used for tinea versicolor [48], knowledge of the potential for hepatotoxicity and the wide availability of safer oral antifungal agents led the European Medicines Agency to release a 2013 recommendation that marketing authorizations for oral ketoconazole be suspended throughout the European Union [49]. The US Food and Drug Administration (FDA) simultaneously removed its indication for use of the drug for dermatophyte and Candida infections based upon risks for hepatotoxicity, adrenal insufficiency, and drug-drug interactions. The FDA also recommended that oral ketoconazole should not be used as a first-line agent for any fungal infection. The indications for treatment of blastomycosis, coccidioidomycosis, histoplasmosis, chromomycosis, and paracoccidioidomycosis have been retained only for patients in whom other antifungal treatments have failed or are not tolerated [50]. (See "Pharmacology of azoles", section on 'Adverse effects'.)
In 2016, following an FDA safety review that found continued prescribing of oral ketoconazole for fungal skin and nail infections, the FDA released a drug safety communication warning healthcare professionals to avoid prescribing oral ketoconazole for fungal skin and nail infections [51]. The risks of oral ketoconazole treatment outweigh the benefits.
Treatment failure — Hypopigmentation and hyperpigmentation can persist for months following successful treatment of tinea versicolor, and may cause patients to assume incorrectly that treatment has failed. The presence of scale plus a positive potassium hydroxide (KOH) preparation is considered indicative of active infection.
Resistance to therapy, frequent recurrence, or widespread disease should prompt consideration of an immunodeficient state (table 3).
PREVENTION — Patients who experience frequent recurrences of tinea versicolor (particularly immunosuppressed individuals) can prevent recurrences with use of topical or oral preventive therapy, particularly during warm weather. In our clinical experience, prophylaxis with topical selenium sulfide 2.5% or ketoconazole 2% shampoo applied to the entire body for ten minutes once per month is an effective therapy.
Oral itraconazole is also used for prophylaxis. In a six-month randomized trial, a greater percentage of subjects were free of recurrent disease after prophylactic treatment with itraconazole (200 mg twice daily for one day per month) than with placebo (88 percent versus 57 percent, respectively) [52]. (See 'Other therapies' above.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Tinea versicolor (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Tinea versicolor is a common fungal skin infection. The disorder occurs worldwide, but is most prevalent in tropical climates. Adolescents and young adults are affected most frequently. Tinea versicolor is not contagious. (See 'Epidemiology' above.)
●Pathogenesis – Malassezia yeasts are a component of normal skin flora. The reasons for the development of tinea versicolor are likely to be multifactorial, involving both exogenous and endogenous factors. Immunosuppressed patients may be at increased risk for the disease. (See 'Pathogenesis and risk factors' above.)
●Clinical features – Patients with tinea versicolor can exhibit hypopigmented, hyperpigmented, or erythematous macules and patches (picture 1A-E). The most common areas of involvement include the upper trunk and proximal upper extremities; facial and intertriginous areas are less frequently affected (picture 3A-B). (See 'Clinical features' above.)
●Diagnosis – The potassium hydroxide (KOH) preparation is a quick and effective way to diagnose tinea versicolor. A Wood's lamp examination will reveal yellow to yellow-green fluorescence in a minority of patients. (See 'Diagnosis' above.)
●Treatment:
•General approach – Topical therapy is a safe and effective treatment for most patients with tinea versicolor. Topical azole antifungals, selenium sulfide, and zinc pyrithione are effective and well-tolerated topical treatments (table 1). Patients should be advised that pigmentary changes may take months to resolve. (See 'First-line therapy' above and 'Treatment failure' above.)
•Patients with extensive disease – For adult patients with extensive disease, we suggest treatment with an oral azole antifungal rather than topical therapy (table 1) (Grade 2B). (See 'Severe or recalcitrant disease' above.)
•Patients with recalcitrant disease – Patients with tinea versicolor who fail topical therapy can be treated with a systemic agent. Treatment regimens are the same as for patients with extensive disease. (See 'Severe or recalcitrant disease' above.)
•Patients with frequent recurrences – Recurrent disease is common. For patients who desire treatment and experience multiple recurrences per year, we suggest prophylactic therapy (Grade 2B). We typically use once-monthly application of selenium sulfide or ketoconazole shampoo. If this regimen is not effective, we prescribe 400 mg of itraconazole (in two divided doses) once monthly for adults during the warm months of the year, when recurrence is most likely. (See 'Prevention' above.)
