Tinea Versicolor (Pityriasis Versicolor)

Introduction

Tinea versicolor is superficial skin infection caused by fungus. This common

disease is most prevalent in the tropics, where there are high humidity and
high temperatures and frequent exposure to sunlight.

Definition

Pityriasis versicolor is a chronic superficial skin infection of Malassezia furfur

leaving hypo or hyperpigmented patches, with fine scale, affecting mostly
trunk upper thighs, upper arms, and sometimes face and scalp.

Etiology

Tinea versicolor is due to Malassezia furfur. The yeast phase of this organism
is classified as Pityrosporum orbiculare.

Clinical manifestation

On the upper trunk and extending onto the upper arms, finely sclalling, guttate
or nummular patches appear, particularly on young adults who perspire freely.
The individual patches are yellowish or brownish macules in lighter skin, or
hypopigmented macules in dark skin, with delicate scalling. Mild itching and
inflammation about the patches may be present. In other instances a follicular
tendency is a marked feature of the eruption. Sites of predilection are the
sternal region and the sides of the chest, the abdomen, back, pubis, neck,
and intertriginous areas. The disease may even occur on the scalp, palms,
and soles. Rarely, the face is involved. Facial lesions occur fairly commonly in
infants and immunocompromised patients.

In hyporpigmented tinea versicolor, the fungus apparently compels the

production of abnormally small melanosomes, which are not transferred to
keratinocytes properly. This hypopigmentation may persist for weeks or
months after the fungal disease is cured.

Diagnosis

Lesions that are imperceptible or doubtful may be brought readily into view in
a darkened room by use of the Wood’s light. This causes fluorescence of the
lessions, which appear yellowish. The Wood’s light also assists in determining
the extent of involvement or the achievement of a cure.

The fungus is easily demonstrated in scrapings of the scales that have been
soaked in 15% solution of KOH. Scales may also be removed by scotch tape,
which is examined directly. Microscopically, there are short, thick fungal
hyphae and large numbers of variously sized spores. This combionation of
strands of mycelium and numerous spores is commonly referred to as ‘
spaghetti and meatballs’. Culture identification is usually done for
epidemiology purposes and is not done to establish the diganosis.

Differential diagnosis

Tinea versicolor must be differentiated from seborrheic dermatitis, pityriasis

alba, pityriasis rosea, leprosy, syphilis, and vitiligo. The diagnosis is generally
easy because of the typical fawn color of the patches. In sebboreheic
dermatitis the patches have an erythematous yellowish tint and the scales are
soft and greasy, whereas in tinea versicolor the scales are furfuraceous. The
macular syphilid consists of faint pink lesions, less than 1 cm in diameter,
irregularly round or oval, which are distributed principally on the nape, sides of
the trunk, and flexor aspects of the extremities. There may be general
adenopathy. The demonstration of this fungus also differentiates this disease
from vitiligo and leprosy. It may be clinically indistinguishable from the latter.

Treatment

Imidazoles, selenium sulfide shampoos, ciclopirox olamine, zinc pyrithione

shampoos, sulfur preparations, salicylic acid preparations, propylene glycol
lotions, and benzoyl peroxide have been used successfully as topical agents.

Ketoconazole 400 mg doses repeated weekly or monthly intervals is very

effective.

Prognosis

The prognosis is good after thorough, consistent treatment. Patients should

be informed that the hypo- and hyperpigmentation will take time to resolve
and is not a sign of treatment failure. Prophylactic treatment could be
instituted if there are signs of relapse after 2 to 12 months.