Pityriasis Versicolor Pityriasis (tinea) versicolor (PV) is a chronic asymptomatic scaling epidermomycosis associated with the superficial overgrowth

of the hyphal form of Malassezia furfur, characterized by well-demarcated scaling patches with variable pigmentation, occurring most commonly on the trunk. Epidemiology and Etiology Etiology M. furfur (previously known as Pityrosporum ovale, P. orbiculare) is a lipophilic yeast that normally resides in the keratin of skin and hair follicles of individuals at puberty and beyond. It is an opportunistic organism, causing pityriasis versicolor and Malassezia folliculitis and is implicated in the pathogenesis of seborrheic dermatitis. Malassezia infections are not contagious; rather, overgrowth of resident cutaneous flora occurs under certain favorable conditions. Age of Onset

Skin Symptoms Usually none. Occasionally, mild pruritus. Individuals with PV usually present because of cosmetic concerns about the blotchy pigmentation. Physical Examination Skin Lesions Macules, sharply marginated (Figs. 23-36, 23-37, and 23-38), round or oval in shape, varying in size. Fine scaling is best appreciated by gently abrading lesions with a no. 15 scalpel blade or the edge of a microscope slide. Treated or burnedout lesions lack scale. Some patients have findings of Malassezia folliculitis and seborrheic dermatitis. In untanned skin, lesions are light brown. On tanned skin, white. In darkskinned individuals, dark brown macules. Brown of varying intensities and hues (Fig. 23-36); off-white macules (Figs. 2337 and 23-38). Some PV lesions are red (Fig. 23-38). In time, individual lesions may enlarge, merge, forming extensive geographic areas. Figure 23-36

Young adults. Less common when sebum production is reduced or absent; tapers off during fifth and sixth decades. Predisposing Factors High temperatures/relative humidity, oily skin, hyperhidrosis, hereditary factors, glucocorticoid treatment, and immunodeficiency. Application of oils such as cocoa butter predisposes young children to PV. Season Temperate zones, appears in summertime, affecting 2% of population; may regress during cooler months; in physically active individuals, may persist year round. Subtropical and tropical zones: year around in 20%. Pathogenesis Malassezia changes from the blastospore form to the mycelial form under the influence of predisposing factors. Dicarboxylic acids formed by enzymatic oxidation of fatty acids in skin surface lipids inhibit tyrosinase in epidermal melanocytes and thereby lead to hypomelanosis. The enzyme is present in the organism. History Duration of Lesions Months to years. Pityriasis versicolor Multiple, small-to-medium-sized, welldemarcated hypopigmented macules on the back of a tanned individual with white skin. Figure 23-38 Pityriasis versicolor Sharply marginated brown macules on the trunk. Fine scale was apparent when the lesions were abraded with the edge of a microscope slide. Figure 23-37

Pityriasis versicolor Follicular, hypopigmented macules on the upper chest of an individual with black skin. Distribution Upper trunk, upper arms, neck, abdomen, axillae, groins, thighs, genitalia. Facial, neck, and/or scalp lesions occur in patients applying creams/ointments or topical glucocorticoid preparations. Differential Diagnosis

Hypopigmented PV Vitiligo, pityriasis alba, postinflammatory hypopigmentation, tuberculoid leprosy. Scaling Lesions Tinea corporis, seborrheic dermatitis, pityriasis rosea, guttate psoriasis, nummular eczema. Laboratory Examinations Direct Microscopic Examination of Scales Prepared with KOH Scale is best obtained with two microscope slides, using one to raise scale and move it onto the other. The harvested scale is moved into a small pile in the center of the slide and covered with a coverslip. KOH solution (15 to 20%) is added at the edge of the coverslip; the slide is gently heated and examined. Filamentous hyphae and globose yeast forms, termed spaghetti and meatballs, are seen (Fig. 23-39). Figure 23-39

Management Topical agents Selenium sulfide (2.5%) lotion or shampoo Apply daily to affected areas for 10 to 15 min, followed by shower, for 1 week Applied same as selenium sulfide shampoo Apply qd or bid for 2 weeks

Ketoconazole shampoo Azole creams (ketoconazole, econazole, micronazole, clotrimazole) Terbinafine 1% solution Systemic therapy (None of these agents is approved for use in PV in the United States) Ketoconazole Fluconazole Itraconazole Secondary prophylaxis

Apply bid for 7 days

400 mg stat (take 1 h before exercise) 400 mg stat 400 mg stat Ketoconazole shampoo once or twice a week Selenium sulfide (2.5%) lotion or shampoo Salicylic acid/sulfur bar Pyrithione zinc (bar or shampoo) Ketoconazole 400 mg PO monthly

Malassezia furfur: KOH preparation Round yeast and elongated pseudohyphal forms, so-called "spaghetti and meatballs." Wood's Lamp Blue-green fluorescence of scales; may be negative in individuals who have showered recently because the fluorescent chemical is water soluble. Vitiligo appears as depigmented, white, and has no scale. Dermatopathology Budding yeast and hyphal forms in the most superficial layers of the stratum corneum, seen best with PAS stain. Variable hyperkeratosis, psoriasiform hyperplasia, chronic inflammation with blood vessel dilatation. Diagnosis Clinical findings, confirmed by positive KOH preparation findings. Course and Prognosis Infection persists for years if predisposing conditions persist. Dyspigmentation persists for months after infection has been eradicated.