Principles of Therapy
Topical therapy is the treatment of choice for pityriasis versicolor. The choice of topical treatment usually depends on what is available and what the patient prefers, including the preferred formulation (such as shampoo versus cream), the length of treatment, and cost. A treatment should not be considered ineffective until persistent infection is confirmed, and possible causes of treatment failure have been evaluated. Persistent light or dark patches are not a dependable sign of treatment failure since discoloration may last for weeks to months after the infection has cleared; when possible, active disease should be verified with a positive KOH test, and the presence of the typical fine scale on examination supports ongoing infection.
An apparent treatment failure should prompt consideration of an incorrect diagnosis or improper use of the therapy. Resistance to topical therapy, frequent relapses, or unusually severe presentations can occur when an underlying immunodeficiency is present. When topical therapy does not lead to improvement, management typically involves either switching to another topical agent or moving on to oral antifungal treatment. Prophylactic therapy can be considered for individuals who have frequent recurrences of tinea versicolor, especially during warmer seasons when relapses are more common.
Pharmacological therapy
Treatment is usually effective but may have to be repeated due to recurrence of infection in susceptible individuals. Prophylactic treatment is recommended for patients at risk of recurrence on exposure to sunlight or warm, humid conditions. Skin discoloration may take several weeks to resolve after completing treatment. If mycology is negative, persisting pale patches do not necessarily warrant additional treatment. Topical agents can be very effective and are safer than systemic medications, especially in children.
Initial Therapy
Selenium sulfide or Ketoconazole shampoo may be used as an initial treatment. Antifungal cream is advised for small areas of skin involvement. Imidazole creams may be used in both children and adults. If initial therapy fails, confirm adherence to treatment. A repeat course of topical treatment should be considered before starting systemic therapy. Other topical agents such as Whitfield ointment, Sulfur-Salicylic acid shampoo, Propylene glycol, and Benzoyl peroxide may be considered, but the patient should be informed about possible adverse effects prior to use.
Topical Antifungals
Pityriasis Versicolor_ManagementTopical antifungals are used as initial treatment of tinea versicolor. Desirable properties include high efficacy, a favorable adverse effects profile, the fewest possible daily applications, the shortest duration of therapy, a low relapse rate, and cost-effectiveness.
Ciclopirox
The topical application of Ciclopirox is proven effective when used twice daily for 2 weeks.
Terbinafine
The efficacy of the topical application of Terbinafine is comparable and may even surpass the effect of imidazoles against tinea infections.
Selenium Sulfide and Zinc Pyrithione
Selenium sulfide and Zinc pyrithione are proven to be effective, safe, and inexpensive for first-line therapy. Topical Selenium sulfide works against Malassezia mainly by accelerating the shedding of the infected stratum corneum, helping remove the fungus along with the superficial skin layers. Selenium sulfide and Zinc pyrithione may be used as a maintenance regimen (apply on the first and third day of each month and leave on for 5 minutes before rinsing).
Imidazoles
Example drugs: Bifonazole, Clotrimazole, Econazole, Fenticonazole, Isoconazole, Ketoconazole, Miconazole, Sertaconazole, Tioconazole
Imidazoles are highly effective, safe, and fairly inexpensive.
Combined Steroid/Imidazole Agents
A high-potency steroid combination is not indicated for treating pityriasis (tinea) versicolor due to the absence of significant inflammation in this condition and the potential of the steroid component to induce atrophy.
Systemic Therapy
Systemic therapy is indicated in cases of severe or widespread skin involvement, recurrent infections, and failure of topical therapy. Oral antifungal agents like Itraconazole and Fluconazole are preferred. Oral Itraconazole is also used for prophylaxis of recurrences. Selection among these treatments depends on the preferred regimen, the patient’s comorbidities, and the potential for drug interactions. Fluconazole is generally used for most patients because it tends to have a more favorable side‑effect profile and fewer significant drug interactions than Itraconazole.
Nonpharmacological
Patient Education
Educate the patient about the basics of yeast growth. Since Malassezia species are lipophilic, advise the patient to avoid oils applied to the skin or in the bath. Pityriasis versicolor is neither contagious nor due to poor hygiene. Avoid the use of occlusive clothing, creams, lotions, and other cosmetic products.