Tinea versicolor (pityriasis versicolor)

INTRODUCTION — Tinea versicolor (ie, pityriasis versicolor) is a common superficial fungal infection that typically presents with hypopigmented, hyperpigmented, or erythematous macules on the trunk and proximal upper extremities (picture 1A-E). Unlike many other disorders utilizing the term "tinea" (eg, tinea pedis, tinea capitis), tinea versicolor is not a dermatophyte infection. The causative organisms are in the genus Malassezia (formerly known as Pityrosporum).

Tinea versicolor typically responds well to therapy (algorithm 1 and table 1A), 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. Other cutaneous superficial fungal infections are reviewed separately.

●(See "Dermatophyte (tinea) infections".)

●(See "Tinea capitis".)

●(See "Tinea nigra".)

●(See "Intertrigo", section on 'Pathogenesis'.)

EPIDEMIOLOGY — Tinea versicolor occurs worldwide.

Tinea versicolor most commonly affects adolescents and young adults but can also occur in children and infants [1-4]. The disorder is not considered contagious, although successful inoculation has occurred under experimental conditions utilizing topical oils and occlusion [5,6].

PATHOGENESIS

●Causative organisms – The causative organisms are saprophytic yeasts in the genus Malassezia (formerly known as Pityrosporum) [7]. 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.

Malassezia globosa appears to be the predominant causal species [8-10]. Malassezia sympodialis, Malassezia furfur, and other Malassezia species have also been implicated [11]. (See "Invasive Malassezia infections".)

●Sites of predilection – 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 [7,12].

●Pigmentary change – Although the reasons for pigmentary variation in tinea versicolor are unconfirmed, 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 [13,14]. Hyperpigmented and erythematous lesions may be a consequence of an inflammatory reaction to the yeast [13].

RISK FACTORS — External factors suspected of contributing to the transformation of Malassezia from yeast cells to a pathogenic, mycelial form include exposure to hot and humid weather, hyperhidrosis, and the use of topical skin oils [15]. 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 [16]. In a questionnaire-based study, 21 percent of patients reported a positive family history of the disease [17]. 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 [18]. One case report describes extensive tinea versicolor after the initiation of the biologic interleukin (IL) 17 inhibitor ixekizumab [19].

CLINICAL FEATURES

●Morphology – The multiple macules, patches, and thin plaques of tinea versicolor can be hypopigmented, hyperpigmented, or mildly erythematous (picture 1A-E). The term "versicolor" refers to the variable changes in cutaneous pigmentation that occur.

The color of hyperpigmented tinea versicolor ranges from light brown to gray-black. In individuals with moderately to highly pigmented skin, hyperpigmented tinea versicolor often presents as dark brown to gray-black lesions (picture 2), and in individuals with lightly to moderately pigmented skin, hyperpigmented tinea versicolor is often light brown to medium brown (picture 1D).

Individual lesions are typically small (eg, <15 mm) and oval or round but frequently coalesce into larger patches or thin plaques. A fine scale is often present, which becomes more apparent when the lesion is scraped for microscopy. (See 'Diagnosis' below.)

●Distribution – 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, facial involvement is common (picture 3A-B) [1,7]. (See 'Pathogenesis' above.)

●Symptoms – Most patients are asymptomatic; occasional patients report mild pruritus. In our experience, the appearance of skin lesions is often the primary concern.

●Course – Tinea versicolor may persist for years without treatment [20]. Recurrence is common after successful treatment [20]. In temperate climates, tinea versicolor often recurs during the warmer months of the year.

Spontaneous resolution is possible; low rates of resolution have been documented in placebo groups in randomized trials [21]. (See 'Management' below.)

DIAGNOSIS — Tinea versicolor should be considered when a patient presents with multiple coalescing, hypopigmented or hyperpigmented macules, patches, or thin plaques on the upper trunk, proximal extremities, neck, or face. Although the diagnosis may be strongly suspected based upon the physical examination, confirmation of the diagnosis with a potassium hydroxide (KOH) preparation should be performed when the diagnosis is uncertain. The variable clinical features of tinea versicolor overlap with the clinical features of other skin diseases. (See 'Clinical features' above and 'Differential diagnosis' below.)

Malassezia species are normal components of skin flora, and detection of Malassezia species through culture or molecular methods is not considered diagnostic [22].

●Physical examination – A full skin examination should be performed. Performance of a full skin examination allows for the recognition of the degree of skin involvement as well as clinical findings that are inconsistent with tinea versicolor. (See 'Differential diagnosis' below.)

Dermoscopy and Wood's lamp examination may exhibit features suggestive of tinea versicolor but do not confirm the diagnosis. Frequent dermoscopic findings appear to be nonuniform pigmentation within lesions, fine scale, and perilesional hyperpigmentation or hypopigmentation [23-25]. Other features have also been reported [23-25]. Examination with a Wood's lamp reveals yellow to yellow-green fluorescence in some patients. It is estimated that fluorescence is present in less than 50 percent of patients [11]. (See "Office-based dermatologic diagnostic procedures", section on 'Wood's lamp examination (black light)'.)

●Potassium hydroxide preparation – The KOH preparation findings in tinea versicolor are considered diagnostic. The preparation demonstrates both short hyphae and yeast cells in a pattern that is often described as "spaghetti and meatballs" (picture 4). (See "Office-based dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation'.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of tinea versicolor consists of common and uncommon skin disorders. The potassium hydroxide (KOH) preparation is a simple and reliable way to distinguish tinea versicolor from other conditions. (See 'Diagnosis' above.)

Examples of skin disorders that may resemble tinea versicolor include:

●Common inflammatory disorders:

•Seborrheic dermatitis – Seborrheic dermatitis on the trunk may present as erythematous, hypopigmented, or hyperpigmented patches or thin patches. In contrast to tinea versicolor, seborrheic dermatitis typically has thicker scale. Patients often exhibit other areas of involvement, such as the scalp, eyebrows, and nasolabial folds (picture 5A-B). (See "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 may exhibit erythema and a collarette of scale (picture 6A-B). In individuals with highly pigmented skin, hyperpigmentation is sometimes prominent (picture 7). (See "Pityriasis rosea".)

•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 8A-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'.)

●Infectious disorders:

•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".)

•Secondary syphilis – Patients with secondary syphilis may present with erythematous to brown macules, papules, or small plaques in a generalized distribution (picture 11). Skin involvement is often present on the palms and soles (picture 12). (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Clinical manifestations'.)

●Other disorders:

•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 13A-B) [26]. 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'.)

•Vitiligo – Vitiligo is an acquired disorder of pigmentation characterized by completely depigmented macules and patches (picture 14A-B). In contrast, tinea versicolor exhibits hypopigmented skin lesions. (See "Vitiligo: Pathogenesis, clinical features, and diagnosis".)

•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 the characteristic findings (picture 15A-D). The neck, chest (particularly intermammary area), and upper back may be affected. (See "Confluent and reticulated papillomatosis".)

•Mycosis fungoides – Mycosis fungoides may present as hypopigmented patches on the skin, with a predilection for the trunk and extremities (picture 16). Fine scale, erythema, or infiltrated plaques may also be present. (See "Variants of mycosis fungoides", section on 'Hypopigmented mycosis fungoides'.)

MANAGEMENT

General principles

●Topical therapy is the treatment of choice [20]. Oral therapy is generally reserved for scenarios in which adequate application of topical therapy is not feasible (eg, extensive disease or limited ability of the patient to administer topical treatment) and for refractory or recurrent disease (algorithm 1 and table 1A) [27]. (See 'Refractory disease or extensive disease' below.)

●Hyperpigmentation and hypopigmentation often persist for weeks to a few months after successful treatment. Because resolution of skin discoloration is often delayed, an assessment for signs of active infection is indicated prior to assuming treatment failure. (See 'Confirming treatment failure' below.)

●High-quality comparative studies of 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 [28]. 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. (See 'Initial therapy' below and 'Refractory disease or extensive disease' below and 'Other therapies' below.)

The methods and timing of response assessment vary across studies. The physical examination and/or microscopic assessment is often used to assess treatment outcomes. The term "mycologic cure" usually refers to a negative potassium hydroxide (KOH) preparation. (See 'Diagnosis' above.)

Patient education — Important patient education concepts include the cause and expected course of tinea versicolor. We inform patients that tinea versicolor is not due to poor hygiene, that it is not contagious, that it usually responds well to treatment, and that recurrence is common. In addition, because persistent, pigmentary changes can be mistaken for active infection, we inform patients that skin discoloration may take weeks to a few months to resolve. (See 'Confirming treatment failure' below and 'Information for patients' below.)

Initial therapy — Topical azole antifungal drugs, topical terbinafine, and topical selenium sulfide are our preferred initial therapies, as these modalities are generally well tolerated and have the most data to support treatment efficacy (algorithm 1 and table 1A) [28]. Selection of a specific agent is generally based upon treatment availability and patient preference (eg, preference for a specific vehicle [eg, shampoo versus cream], treatment duration, or cost). Topical zinc pyrithione is a reasonable alternative. Other topical interventions may also be effective. (See 'Alternative therapy' below and 'Other therapies' below.)

Topical azole antifungal drugs — Topical azole antifungal drugs have direct antifungal activity and are considered effective for tinea versicolor (table 1A-B).

●Administration – Topical azole antifungal drugs are available in a variety of formulations, including shampoos, creams, foams, gels, and solutions (table 1B). Ketoconazole 2% shampoo is our preferred formulation because of demonstrated efficacy of a short course of treatment and the relative ease of application of shampoo to large body areas. However, use of other topical azole antifungal drugs is reasonable. Examples of other formulations with evidence of efficacy include clotrimazole, bifonazole, miconazole, and econazole [28,29].

Ketoconazole 2% shampoo is applied to affected areas and washed off after five minutes. We typically advise patients to treat for three consecutive days. A typical treatment course for other formulations of ketoconazole (eg, cream, foam) and other topical azole antifungal drugs is daily application for two weeks. However, shorter durations may be sufficient for some treatments [30-32].

Efficacy of a one-day regimen for ketoconazole 2% shampoo has also been reported [33]. However, given the frequent location of tinea versicolor in body sites that can be challenging to view 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 days to increase the likelihood of adequate treatment.

Unlike the 2% formulation, ketoconazole 1% shampoo is available without a prescription in the United States. Although ketoconazole 1% shampoo is sometimes used for tinea versicolor in clinical practice, its efficacy for tinea versicolor has not been evaluated.

●Efficacy – Multiple small, randomized trials support the efficacy of various topical azole antifungal drugs compared with placebo [21,28]. For example, in one randomized trial (n = 101), ketoconazole 2% cream applied once daily for 11 to 22 days (mean 14 days) was superior to placebo (mycologic cure in 84 versus 22 percent of patients) [34].

Another trial found three-day and one-day regimens for ketoconazole 2% shampoo more effective than placebo and found similar efficacy for the two ketoconazole regimens [33]. In the trial, 322 patients with tinea versicolor were randomly assigned to a five-minute application of ketoconazole 2% shampoo for one day, ketoconazole 2% shampoo for three days, or placebo shampoo for three days. At day 31, rates of mycologic cure (based upon cellophane tape test results for 310 patients) were 78, 84, and 11 percent, respectively.

A randomized trial (n = 40) that compared once-daily application of ketoconazole 2% cream for 14 days with once-daily application of clotrimazole 1% cream for 14 days did not find a statistically significant difference in efficacy [35]. Azole antifungal drugs have also been compared with other types of treatments [21]. (See 'Topical terbinafine' below and 'Selenium sulfide' below.)

Topical terbinafine — Topical terbinafine is an allylamine antifungal drug.

●Administration – Terbinafine is available as a nonprescription 1% cream in the United States as well as in a solution form in some other locations. Various treatment regimens have been utilized, ranging from once- to twice-daily application for one to four weeks [21]. A reasonable regimen is twice-daily application for one week.

●Efficacy – Topical terbinafine 1% solution applied twice daily for one week has been effective in randomized trials [21]. In one of the largest trials (n = 288), twice-daily application of terbinafine 1% solution was superior to placebo [36]. Mycologic cure rates at week 8 were 64 and 33 percent, respectively.

Smaller, randomized trials comparing terbinafine 1% cream with similar application regimens of ketoconazole 2% cream (once- or twice-daily application for 14 days), bifonazole cream (twice-daily application for up to four weeks), or eberconazole 1% cream (once daily for two weeks) have not found statistically significant differences in efficacy among the treatments [37-40].

Selenium sulfide — Topical selenium sulfide exerts antifungal activity primarily through the promotion of shedding of the infected stratum corneum.

●Administration – Selenium sulfide is available as a 2.25% or 2.5% shampoo and a 2.5% lotion (depending on location). A reasonable regimen for these formulations is application to the affected area once daily for one week. The shampoo or lotion is rinsed off after 10 minutes.

In the United States, unlike the higher concentrations of selenium sulfide, selenium sulfide 1% shampoo can be obtained without a prescription. Although this formulation is sometimes used for tinea versicolor in clinical practice, its efficacy for tinea versicolor has not been studied.

Some patients may find the odor of selenium sulfide unpleasant [41].

●Efficacy – In a trial that compared selenium sulfide 2.5% shampoo applied once daily for seven days with oral itraconazole (at a dose of 200 mg once daily for five days) in 40 patients with tinea versicolor, complete clinical responses (resolution of scale, erythema, and pruritus) occurred in 85 percent of patients treated with itraconazole versus 80 percent of patients treated with selenium sulfide three weeks after the end of treatment [41]. However, among the complete clinical responders, microscopy remained positive in seven patients in the itraconazole group and in none in the selenium sulfide group.

In another randomized trial (n = 167), application of selenium sulfide 2.5% lotion, selenium sulfide 2.5% lotion with added colorants, or vehicle for 10 minutes for seven days was associated with mycologic cure rates of 87, 71, and 16 percent, respectively [42]. The efficacy analysis excluded 35 patients who did not complete the study.

Other randomized trials comparing selenium sulfide shampoo with bifonazole solution or econazole 1% shampoo suggest similar benefit of selenium sulfide therapy [43,44].

Alternative therapy — Benefits of zinc pyrithione 1% shampoo for tinea versicolor include the ease of shampoo application and the wide nonprescription availability of this product. However, compared with ketoconazole and selenium sulfide (also available in shampoo), clinical trial data for zinc pyrithione are more limited and have focused on a longer course of treatment.

Zinc pyrithione — Zinc pyrithione 1% shampoo may be administered as one five-minute application per day for two weeks. Subsequently, the shampoo is rinsed off the skin. In the United States, this agent does not require a prescription.

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 shampoo vehicle [45]. Four weeks after the end of treatment, none of the 20 patients treated with zinc pyrithione 1% shampoo had positive microscopy or evidence of Wood's light fluorescence compared with positive microscopy in 14 of 20 patients (70 percent) in the shampoo vehicle group and positive fluorescence in all patients in the shampoo vehicle group.

Refractory disease or extensive disease — Oral antifungal therapy is typically reserved for tinea versicolor that is refractory to topical therapy, recurs frequently, or is associated with a scenario in which adequate application of topical therapy is not feasible (eg, extensive disease or limited ability of the patient to administer topical treatment) (algorithm 1) [7,27]. Oral antifungal therapy is not preferred for most patients because of greater risk for drug interactions and systemic adverse effects compared with topical therapy. When oral treatment is necessary, fluconazole or itraconazole is typically used (table 1A).

Confirming treatment failure — Prior to assuming a treatment for tinea versicolor is ineffective, the patient should be evaluated to confirm persistent infection, and potential reasons for treatment failure should be assessed.

●Interpretation of skin findings – Persistent hypopigmentation or hyperpigmentation is not a reliable indicator of treatment failure. Skin discoloration can persist for weeks to a few months after successful treatment. If feasible, active infection should be confirmed with a positive KOH preparation. The presence of the characteristic fine scale of tinea versicolor is a clinical sign that suggests active infection. (See 'Diagnosis' above.)

●Assessment for reasons for inefficacy – The possibilities of an incorrect diagnosis and inadequate treatment administration should be considered when there is an apparent treatment failure.

Of note, resistance to topical therapy, frequent recurrence, or unusually severe tinea versicolor may occur in the setting of underlying immunodeficiency.

Treatment selection — When topical treatment is ineffective, options include switching to a different topical therapy or proceeding to oral antifungal therapy (algorithm 1).

Oral fluconazole and oral itraconazole are the preferred antifungal therapies for patients who require oral treatment. Selection between these therapies is based upon regimen preference, patient comorbidities, and consideration of drug interactions. We treat most patients with fluconazole because of a more favorable adverse effect profile and fewer serious drug interactions compared with itraconazole. (See "Pharmacology of azoles", section on 'Adverse effects' and "Pharmacology of azoles", section on 'Drug interactions'.)

Oral fluconazole — Various regimens for fluconazole have been utilized [21,46]. Our preferred fluconazole regimen for tinea versicolor in adults is a single 300 mg dose taken once weekly for two weeks [46].

One of the largest trials was an open, randomized trial (n = 608) that compared fluconazole doses of 150 mg once weekly for four weeks, 300 mg once weekly for four weeks, and 300 mg given once and then repeated in two weeks [47]. After the initial dose of fluconazole, subsequent doses were given only if patients exhibited clinical or microscopic evidence of infection. Mycologic cure rates at the last follow-up visit were 78, 93, and 87 percent, respectively, with both 300 mg regimens superior to the 150 mg dose regimen.

Fluconazole given as 300 mg per week for two weeks was assessed in other studies. In an open, randomized trial, fluconazole 300 mg per week for two weeks was superior to both a single 450 mg dose of fluconazole and a 200 mg dose of itraconazole given for seven days (97, 70, and 80 percent of patients, respectively, achieved mycologic cure one month after the end of treatment) [48]. In a small, uncontrolled study, fluconazole 300 mg once weekly for two weeks was associated with mycologic and clinical cure in 75 percent of patients at week 4 [49].

In an uncontrolled study of 24 individuals with extensive or recurrent tinea versicolor treated with a single 400 mg dose of fluconazole, 74 percent had resolution of clinical disease three weeks after treatment [50].

Oral itraconazole — Various regimens for oral itraconazole have been utilized [21,46]. Our preferred regimen for itraconazole for adults is 200 mg per day for five days. Some authors utilize a seven-day treatment course for extensive disease [46].

Small, primarily open, randomized trials have reported mycologic cure rates between 50 and 96 percent for 200 mg of itraconazole daily for five days and between 70 and 90 percent for 200 mg of itraconazole daily for seven days [21,46]. A difference in efficacy has not been proven. In an open, randomized trial that directly compared these regimens (n = 28), all patients exhibited clinical improvement by four weeks after treatment, and both clinical resolution and negative cultures were identified in 10 of 13 patients (77 percent) treated for five days and in 13 of 15 patients (87 percent) treated for seven days [51]. An analysis for statistical significance was not performed.

Data conflict on the efficacy of a single 400 mg dose of itraconazole. In an open, randomized trial (n = 50), a single 400 mg dose was as effective as 200 mg daily for seven days (mycologic cure at six weeks in 85 and 90 percent of patients, respectively) [52]. However, a low rate of response (based upon culture results) was reported in a trial (n = 40) that compared a single 400 mg dose of fluconazole and a single 400 mg dose of itraconazole (65 percent of patients given fluconazole versus 20 percent of patients given itraconazole were culture negative after eight weeks) [53].

Oral antifungal drugs to avoid — In contrast to topical terbinafine, oral terbinafine is not considered effective [54]. Oral terbinafine may not be secreted in sufficient levels in sweat to treat tinea versicolor adequately [21]. Oral griseofulvin has also not demonstrated efficacy for tinea versicolor.

Oral ketoconazole should not be used for the treatment of tinea versicolor due to safety concerns [55,56]. Although oral ketoconazole was effective for tinea versicolor in small, randomized trials [57,58], life-threatening hepatotoxicity and adrenal insufficiency, along with multiple potential drug-drug interactions, have been reported with oral ketoconazole therapy. (See "Pharmacology of azoles", section on 'Ketoconazole'.)

Other therapies — Additional topical therapies have been used for the treatment of tinea versicolor.

Topical ciclopirox — Topical ciclopirox olamine 1% cream appeared effective for tinea versicolor and superior to clotrimazole 1% cream in two randomized trials performed by the same investigators [59]. In the trial that compared twice-daily application of ciclopirox olamine 1% cream for two weeks with vehicle (n = 153), both clinical and mycologic cure were present in 49 percent of 73 patients in the ciclopirox group and in 24 percent of 72 patients in the vehicle group at the end of two weeks of treatment. In the trial that compared twice-daily application of ciclopirox olamine 1% cream for two weeks with twice-daily application of clotrimazole 1% cream (n = 122), this endpoint occurred in 77 percent of 60 patients in the ciclopirox group compared with 45 percent of 53 patients in the clotrimazole group.

Other — Whitfield ointment (3% salicylic acid and 6% benzoic acid in an emulsifying base) [60,61] and sulfur-salicylic acid shampoo [62] appeared effective for tinea versicolor in small, randomized trials but may cause skin irritation in a minority of patients. Small, uncontrolled studies suggest that propylene glycol [63] and benzoyl peroxide [64] may also improve tinea versicolor.

Uncontrolled studies suggest benefit of topical naftifine for tinea versicolor [20]. An unpublished, randomized trial suggests benefit of topical butenafine [65].

PREVENTION — Prophylactic therapy is an option for patients who experience frequent recurrences of tinea versicolor (eg, multiple recurrences per year), particularly during warm seasons. However, data on prophylactic therapy are limited. In our experience, prophylaxis with topical selenium sulfide 2.25% shampoo or ketoconazole 2% shampoo applied to the entire body for 10 minutes once per month has seemed beneficial.

Oral antifungal prophylactic therapy is an alternative approach for patients in whom topical therapy is not effective or feasible. Oral itraconazole (at a dose of 200 mg twice daily given for one day per month) is a reasonable regimen for adults. In a six-month, randomized trial (n = 209), a greater percentage of patients were free of recurrent disease after prophylactic treatment with itraconazole (at a dose of 200 mg twice daily for one day per month) than with placebo (88 versus 57 percent, respectively) [66]. (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 5^th to 6^th 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 10^th to 12^th 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 superficial fungal skin infection that occurs most often in adolescents and young adults. (See 'Epidemiology' above.)

●Pathogenesis – Tinea versicolor is not a dermatophyte infection. The causative organisms are saprophytic, lipid-dependent yeasts in the genus Malassezia (formerly known as Pityrosporum). 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. (See 'Pathogenesis' above.)

●Clinical features – Patients with tinea versicolor exhibit hypopigmented, hyperpigmented, or erythematous macules, patches, or thin plaques (picture 1A-E). Fine scale that becomes more apparent when lesions are scraped for microscopy is often present. The upper trunk and proximal upper extremities are the most common sites of involvement. Less often, facial or intertriginous areas are affected (picture 3A-B). (See 'Clinical features' above.)

●Diagnosis – A diagnosis of tinea versicolor may be strongly suspected based upon the physical examination. A potassium hydroxide (KOH) preparation demonstrating short hyphae and yeast cells confirms the diagnosis (picture 4). The appearance of the fungal elements in the KOH preparation is often described as "spaghetti and meatballs." (See 'Diagnosis' above.)

●Treatment:

•General approach – For most patients with tinea versicolor, we suggest treatment with a topical azole antifungal drug, topical terbinafine, or topical selenium sulfide rather than other therapies (algorithm 1 and table 1A) (Grade 2C). Factors such as treatment availability, patient preference, and cost influence selection among these treatments. Zinc pyrithione shampoo is a reasonable alternative; however, efficacy data are more limited. (See 'General principles' above and 'Initial therapy' above.)

We frequently treat with ketoconazole 2% shampoo because of ease of application and evidence for efficacy of a short course of treatment. (See 'Topical azole antifungal drugs' above.)

•Topical therapy ineffective or not feasible:

-Confirmation of active infection – Reassessment of the diagnosis and confirmation of active infection are important if tinea versicolor appears to fail to respond to treatment. Skin discoloration may persist for weeks to a few months after successful treatment. (See 'Confirming treatment failure' above.)

-Treatment selection – For patients in whom topical therapy is not effective or feasible (eg, adequate application not feasible due to extent of disease or patient ability), we suggest oral fluconazole rather than other treatments (algorithm 1 and table 1A) (Grade 2C). Oral itraconazole is a reasonable alternative. Due to safety concerns, oral ketoconazole should not be used for treatment. (See 'Refractory disease or extensive disease' above.)

•Frequent recurrences – Recurrent tinea versicolor is common. For patients who experience multiple recurrences per year and who desire prophylaxis, we suggest topical prophylactic therapy rather than oral prophylactic therapy (Grade 2C). We typically use once-monthly application of selenium sulfide 2.25% shampoo or ketoconazole 2% shampoo.

Patients for whom topical prophylactic therapy is ineffective can be treated with oral prophylactic therapy. We typically prescribe itraconazole taken for one day per month during the warm months of the year. (See 'Prevention' above.)