1/3/2016

TineaVersicolorClinicalPresentation:History,Physical,Causes

TineaVersicolorClinicalPresentation
Author:CraigGBurkhart,MD,MPHChiefEditor:DirkMElston,MDmore...
Updated:Nov19,2015

History
Mostindividualswithtineaversicolorreportcosmeticallydisturbing,abnormalpigmentation.Theinvolvedskin
regionsareusuallythetrunk,theback,theabdomen,andtheproximalextremities.Theface,thescalp,andthe
genitaliaarelesscommonlyinvolved.Thecolorofeachlesionvariesfromalmostwhitetoreddishbrownorfawn
colored.Afine,dustlikescalecoversthelesions.
Tineaversicolorpatientsoftenreportthattheinvolvedskinlesionsfailtotaninthesummer.
Occasionally,atineaversicolorpatientalsoreportsmildpruritus.
Greaterthan20%oftineaversicolorpatientsreportapositivefamilyhistoryofthecondition.Thissubsetofpatients
recordsahigherrateofrecurrenceandlongerdurationofdisease. [8]

Physical
Tineaversicolorcanpresentin4forms.

TineaversicolorForm1
Themostcommonappearanceofthediseaseisasnumerous,wellmarginated,finelyscaly,ovaltoroundmacules
scatteredoverthetrunkand/orthechest,withoccasionalextensiontothelowerpartoftheabdomen,theneck,and
theproximalextremities.
Themaculestendtocoalesce,formingirregularlyshapedpatchesofpigmentaryalteration.Asthenameversicolor
implies,thediseasecharacteristicallyrevealsavarianceinskinhue.Theinvolvedareascanbeeitherdarkeror
lighterthanthesurroundingskin.
Theconditionismorenoticeableduringthesummermonthswhenthediscrepancyincolorfromthenormalskin
becomesmoreapparent.
Lightscrapingoftheinvolvedskinwithascalpelbladecharacteristicallyyieldsacopiousamountofkeratin.

TineaversicolorForm2
Aninverseformoftineaversicoloralsoexistsinwhichtheconditionhasanentirelydifferentdistribution,affecting
theflexuralregions,theface,orisolatedareasoftheextremities.Thisformoftineaversicolorismoreoftenseenin
hostswhoareimmunocompromised.
Thisformofthediseasecanbeconfusedwithcandidiasis,seborrheicdermatitis,psoriasis,erythrasma,and
dermatophyteinfections.

TineaversicolorForm3
ThethirdformofMalasseziainfectionsoftheskininvolvesthehairfollicle.Thisconditionistypicallylocalizedtothe
back,thechest,andtheextremities.
Thisformcanbeclinicallydifficulttodifferentiatefrombacterialfolliculitis.ThepresentationofPityrosporum
folliculitisisaperifollicular,erythematouspapuleorpustule.
Predisposingfactorsincludediabetes,highhumidity,steroidorantibiotictherapy,andimmunosuppressanttherapy.
Additionally,severalreportsrevealthatMfurfuralsoplaysaroleinseborrheicdermatitis.

TineaversicolorForm4
Anotherclinicalpresentationismultiplefirm,2to3mm,monomorphic,redbrown,inflammatorypapules.These
lesionsmay,ormaynotalsodemonstrateafinewhitescale.
Thelesionsareusuallyfoundonthetorsoandareasymptomatic.
Histologically,therashdemonstratesnotonlyfungalhyphaeandsporesinthestratumcorneum,butalsoan
interfacedermatitisinthesuperficialdermis. [9]

Causes
Mostcasesoftineaversicoloroccurinhealthyindividualswithnoimmunologicdeficiencies.Nevertheless,several
factorspredisposesomepeopletodevelopthiscondition.Thesefactorsincludegeneticpredispositionwarm,humid
environmentsimmunosuppressionmalnutritionapplicationofoilypreparationscorticosteroidusageandCushing
disease. [10,11,12]
Thereasonwhythisorganismcausestineaversicolorinsomeindividualswhileremainsasnormalflorainothersis
notentirelyknown.Severalfactors,suchastheorganism'snutritionalrequirementsandthehost'simmuneresponse
totheorganism,aresignificant.

http://emedicine.medscape.com/article/1091575clinical#b4

1/4

1/3/2016

TineaVersicolorClinicalPresentation:History,Physical,Causes

Theorganismislipophilic,andlipidsareessentialforgrowthinvitroandinvivo.Furthermore,themycelialstage
canbeinducedinvitrobytheadditionofcholesterolandcholesterolesterstotheappropriatemedium.Becausethe
organismmorerapidlycolonizeshumansduringpubertywhenskinlipidsareincreasedmorethanthatofadolescent
levelsandtineaversicolorismanifestedinsebumrichareas(eg,chest,back),individualvariationsinskinsurface
lipidsarehypothesizedtoplayamajorroleindiseasepathogenesis.However,patientswithtineaversicolorand
controlsubjectsdonotdemonstrateanyquantitativeorqualitativedifferencesinskinsurfacelipids.Skinsurface
lipidsaresignificantforthenormalpresenceofMfurfuronhumanskin,buttheyprobablyplaylittleroleinthe
pathogenesisoftineaversicolor.
Evidencehasbeenaccumulatingtosuggestthataminoacids,ratherthanlipids,arecriticalfortheappearanceof
thediseasedstate.Invitro,theaminoacidasparaginestimulatesthegrowthoftheorganism,whileanotheramino
acid,glycine,induceshyphalformation.Invivo,theaminoacidlevelshavebeenshowntobeincreasedinthe
uninvolvedskinofpatientswithtineaversicolorin2separatestudies.
Anothersignificantcausativefactoristhepatient'simmunesystem.AlthoughsensitizationagainstMfurfurantigens
isroutinelypresentinthegeneralpopulation(asprovenbylymphocytetransformationstudies),lymphocytefunction
onstimulationwiththeorganismhasbeenshowntobeimpairedinpatientswhoareaffected.Thisoutcomeis
similartothesituationofsensitizationwithCandidaalbicans.Inshort,cellmediatedimmunityplayssomerolein
diseasecausation.
Oxidativestressasshownbyexpressionofreducedglutathionecontributestothepathogenesisofthiscondition. [13]
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
CraigGBurkhart,MD,MPHClinicalProfessor,DepartmentofMedicine,MedicalCollegeofOhioClinical
AssistantProfessor,DepartmentofMedicine,OhioUniversityCollegeofOsteopathicMedicine
CraigGBurkhart,MD,MPHisamemberofthefollowingmedicalsocieties:AssociationofMilitary
Dermatologists,AmericanCollegeofAestheticandCosmeticPhysiciansAmericanSocietyof
Aesthetic/CosmeticPhysicians,MichiganDermatologicalSociety,AcademyofMedicineofToledoandLucas
County,OhioDermatologicalAssociation,AmericanAcademyofDermatology,OhioStateMedicalAssociation,
PhiBetaKappa
Disclosure:Nothingtodisclose.
Coauthor(s)
CraigNBurkhart,MDMSBS,AssistantProfessor,DepartmentofDermatology,UniversityofNorthCarolinaat
ChapelHillSchoolofMedicine
CraigNBurkhart,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanCollegeofPhysicians,AmericanMedicalAssociation
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MichaelJWells,MD,FAADAssociateProfessor,DepartmentofDermatology,TexasTechUniversityHealth
SciencesCenter,PaulLFosterSchoolofMedicine
MichaelJWells,MD,FAADisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofDermatology,AmericanMedicalAssociation,TexasMedicalAssociation
Disclosure:Nothingtodisclose.
EdwardFChan,MDClinicalAssistantProfessor,DepartmentofDermatology,UniversityofPennsylvania
SchoolofMedicine
EdwardFChan,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanSocietyofDermatopathology,SocietyforInvestigativeDermatology
Disclosure:Nothingtodisclose.
ChiefEditor
DirkMElston,MDProfessorandChairman,DepartmentofDermatologyandDermatologicSurgery,Medical
UniversityofSouthCarolinaCollegeofMedicine
DirkMElston,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology
Disclosure:Nothingtodisclose.
AdditionalContributors
KathrynSchwarzenberger,MDAssociateProfessorofMedicine,DivisionofDermatology,Universityof
VermontCollegeofMedicineConsultingStaff,DivisionofDermatology,FletcherAllenHealthCare
KathrynSchwarzenberger,MDisamemberofthefollowingmedicalsocieties:Women'sDermatologicSociety,
AmericanContactDermatitisSociety,MedicalDermatologySociety,DermatologyFoundation,AlphaOmega
Alpha,AmericanAcademyofDermatology
Disclosure:Nothingtodisclose.
Acknowledgements
LorieGottwald,MDChief,DivisionofDermatology,AssociateProfessor,DepartmentofInternalMedicine,
MedicalCollegeofOhioatToledo
LorieGottwald,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanCollegeofPhysicians,AmericanMedicalAssociation,AmericanMedicalStudent
Association/Foundation,andAmericanMedicalWomen'sAssociation

http://emedicine.medscape.com/article/1091575clinical#b4

2/4

1/3/2016

TineaVersicolorClinicalPresentation:History,Physical,Causes

Disclosure:Nothingtodisclose.

References
1. CrespoErchigaV,FlorencioVD.Malasseziayeastsandpityriasisversicolor.CurrOpinInfectDis.2006
Apr.19(2):13947.[Medline].
2. GaitanisG,VelegrakiA,AlexopoulosEC,ChasapiV,TsigoniaA,KatsambasA.DistributionofMalassezia
speciesinpityriasisversicolorandseborrhoeicdermatitisinGreece.Typingofthemajorpityriasisversicolor
isolateM.globosa.BrJDermatol.2006May.154(5):8549.[Medline].
3. MorishitaN,SeiY,SugitaT.Molecularanalysisofmalasseziamicroflorafrompatientswithpityriasis
versicolor.Mycopathologia.2006Feb.161(2):615.[Medline].
4. RinconS,CelisA,SopoL,MottaA,CeperodeGarciaMC.Malasseziayeastspeciesisolatedfrom
patientswithdermatologiclesions.Biomedica.2005Jun.25(2):18995.[Medline].
5. KrisantyRI,BramonoK,MadeWisnuI.IdentificationofMalasseziaspeciesfrompityriasisversicolorin
Indonesiaanditsrelationshipwithclinicalcharacteristics.Mycoses.2009May.52(3):25762.[Medline].
6. BlaesAH,CavertWP,MorrisonVA.Malassezia:isitapulmonarypathogeninthestemcelltransplant
population?.TransplantInfectiousDisease.August,2009.11:313317.[Medline].
7. MuhammadN,KamalM,IslamT,IslamN,ShafiquzzamanM.Astudytoevaluatetheefficacyandsafety
oforalfluconazoleinthetreatmentoftineaversicolor.MymensinghMedJ.2009Jan.18(1):315.
[Medline].
8. HeSM,DuWD,YangS,etal.ThegeneticepidemiologyoftineaversicolorinChina.Mycoses.2008Jan.
51(1):5562.[Medline].
9. SuwatteeP,ChamPM,SolomonRK,KayeVN.Tineaversicolorwithinterfacedermatitis.JCutanPathol.
2009Feb.36(2):2856.[Medline].
10. BurkhartCG,DvorakN,StockardH.Anunusualcaseoftineaversicolorinanimmunosuppressedpatient.
Cutis.1981.27(1):568.[Medline].
11. GulecAT,DemirbilekM,SeckinD,etal.Superficialfungalinfectionsin102renaltransplantrecipients:a
casecontrolstudy.JAmAcadDermatol.2003Aug.49(2):18792.[Medline].
12. MendezTovarLJ.Pathogenesisofdermatophytosisandtineaversicolor.ClinicsinDermatology.2010.
28:185188.[Medline].
13. KilicM,OguztuzumS,KaradagS,CakirE,AydinM,OzturkL.ExpressionofGSTM4andGSTT1in
patientswithTineaversicolor,Tineainguinalis,andTineapedisinfections:apreliminarystudy.Clinical
Dermatology.2011.36:590594.[Medline].
14. LimSL,LimCS.Newcontraststainfortherapiddiagnosisofpityriasisversicolor.ArchDermatol.2008
Aug.144(8):10589.[Medline].
15. JanakiC,SentamilselviG,JanakiVR,BoopalrajJM.UnusualobservationsinthehistologyofPityriasis
versicolor.Mycopathologia.1997.139(2):714.[Medline].
16. GuptaAK,LyonsDC.Pityriasisversicolor:anupdateonpharmacologicaltreatmentoptions.ExpertOpin
Pharmacother.2014Aug.15(12):170713.[Medline].
17. GuptaAK,SkinnerAR.Ciclopiroxforthetreatmentofsuperficialfungalinfections:areview.IntJ
Dermatol.2003Sep.42Suppl1:39.[Medline].
18. HullCA,JohnsonSM.Adoubleblindcomparativestudyofsodiumsulfacetamidelotion10%versus
seleniumsulfidelotion2.5%inthetreatmentofpityriasis(tinea)versicolor.Cutis.2004Jun.73(6):4259.
[Medline].
19. VermeerBJ,StaatsCC.Theefficacyofatopicalapplicationofterbinafine1%solutioninsubjectswith
pityriasisversicolor:aplacebocontrolledstudy.Dermatology.1997.194Suppl1:224.[Medline].
20. CarrilloMunozAJ,GiusianoG,EzkurraPA,QuindosG.Sertaconazole:updatedreviewofatopical
antifungalagent.ExpertRevAntiInfectTher.2005Jun.3(3):33342.[Medline].
21. GoldM,BridgesT,AvakianE,PlaumS,PappertEJ,FleischerAB,etal.Anopenlabelstudyofnaftifine
hydrochloride1%gelinthetreatmentoftineaversicolor.SkinMed.Sept2011.9:2836.[Medline].
22. CroxtallJ,PloskerG.Sertaconazole:areviwofitsuseinthemanagementofsuperficialmycosesin
dermatologyandgynacology.Ingenta/AdisInternational.Jan2009.69:339359.[Medline].
23. CantrellWC,ElewksiBE.Canpityriasisversicolorbetreatedwith2%ketoconazolefoam?.JDrugs
Dermatol.2014Jul1.13(7):8559.[Medline].
24. HickmanJG.Adoubleblind,randomized,placebocontrolledevaluationofshorttermtreatmentwithoral
itraconazoleinpatientswithtineaversicolor.JAmAcadDermatol.1996May.34(5Pt1):7857.[Medline].
25. KarakasM,DurduM,MemisogluHR.Oralfluconazoleinthetreatmentoftineaversicolor.JDermatol.
2005Jan.32(1):1921.[Medline].
26. PartapR,KaurI,ChakrabartiA,KumarB.Singledosefluconazoleversusitraconazoleinpityriasis
versicolor.Dermatology.2004.208(1):559.[Medline].
27. FernandezNavaHD,LayaCuadraB,TiancoEA.Comparisonofsingledose400mgversus10day200
mgdailydoseketoconazoleinthetreatmentoftineaversicolor.IntJDermatol.1997Jan.36(1):646.
[Medline].

http://emedicine.medscape.com/article/1091575clinical#b4

3/4

1/3/2016

TineaVersicolorClinicalPresentation:History,Physical,Causes

28. WahabMA,AliME,RahmanMH,ChowdhurySA,MonamieNS,SultanaN,etal.Singledose(400mg)
versus7day(200mg)dailydoseitraconazoleinthetreatmentoftineaversicolor:arandomizedclinicaltrial.
MymensinghMedJ.2010Jan.19(1):726.[Medline].
29. FaergemannJ,ToddG,PatherS,etal.Adoubleblind,randomized,placebocontrolled,dosefinding
studyoforalpramiconazoleinthetreatmentofpityriasisversicolor.JAmAcadDermatol.2009Dec.
61(6):9716.[Medline].
30. GuptaAK,LaneD,PaquetM.Systematicreviewofsystemictreatmentsfortineaversicolorandevidence
baseddosingregimenrecommendations.JCutanMedSurg.2014MarApr.18(2):7990.[Medline].
31. MellenLA,ValleeJ,FeldmanSR,FleischerABJr.TreatmentofpityriasisversicolorintheUnitedStates.
JDermatologTreat.2004Jun.15(3):18992.[Medline].
32. LeemingJP,SansomJE,BurtonJL.SusceptibilityofMalasseziafurfursubgroupstoterbinafine.BrJ
Dermatol.1997Nov.137(5):7647.[Medline].
33. FaergemannJ,GuptaAK,AlMofadiA,AbanamiA,ShareaahAA,MarynissenG.Efficacyofitraconazole
intheprophylactictreatmentofpityriasis(tinea)versicolor.ArchDermatol.2002Jan.138(1):6973.
[Medline].
34. KimYJ,KimYC.Successfultreatmentofpityriasisversicolorwith5aminolevulinicacidphotodynamic
therapy.ArchDermatol.2007Sep.143(9):121820.[Medline].
35. QiaoJ,LiR,DingY,FangH.Photodynamictherapyinthetreatmentofsuperficialmycoses:anevidence
basedevaluation.Mycopathologia.2010.170:339343.[Medline].
36. BurkhartCG.Tineaversicolor.JDermatolAllergy.1983.6:812.
MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/1091575clinical#b4

4/4