BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 1 of 6
Practice
PRACTICE PRACTICE POINTER
Pityriasis versicolor 1
2
Sruthi Renati , Anthony Cukras , Michael Bigby
2
Harvard Medical School, Boston, Massachusetts, USA; 2Department of Dermatology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA 02215, USA 1
What is pityriasis versicolor? Pityriasis versicolor is a superficial fungal infection of the skin. It is caused by Malassezia, a lipophilic dimorphic fungus. This fungus is part of the normal skin flora but can cause disease when it converts to its pathogenic hyphal form. Certain environmental, genetic, and immunological factors can predispose to this pathogenic conversion and contribute to the development of disease.
The fungus grows best in warm and humid conditions, explaining the higher prevalence of pityriasis versicolor in humid tropical climates. A survey in central Sweden found a 0.5% prevalence of pityriasis versicolor, whereas the prevalence is as high as 50% in tropical countries.1 2 There is a significant increase in disease prevalence between childhood and adolescence, probably due to hormonal changes that increase sebum production and allow for a more lipid-rich environment in which the fungus can grow. The disease is also more common among adolescents and young adults who are physically active.3 Although effective oral and topical treatment options exist, disease recurrence is common and pityriasis versicolor can have an impact on quality of life.4
How does pityriasis versicolor present? Patients with pityriasis versicolor present with a rash consisting of well demarcated, finely scaling, thin plaques (fig 1⇓). These plaques can be hyperpigmented, hypopigmented, or erythematous and occasionally become confluent and widespread. The fine scale present on the lesions becomes more apparent when the affected skin is stretched or scraped (fig 1). The distribution of affected skin is theorised to reflect the lipophilic nature of the fungus and its preference for sebum-rich skin. The rash commonly affects the torso but can be widespread, and the face is particularly affected in children.5 The skin lesions are generally asymptomatic or mildly pruritic but can be severely pruritic in certain humid conditions.6 A concerning feature of the disease is that hyperpigmentation or hypopigmentation associated with the rash often persists for months after the fungal infection is appropriately treated.
How is pityriasis versicolor diagnosed? Pityriasis versicolor can be clinically diagnosed by its characteristic skin lesions (erythematous, hyperpigmented or hypopigmented, finely scaling, thin plaques). The fine scale on the affected skin is not easily seen but becomes more apparent when the skin is stretched or scraped (the “evoked scale sign”). This sign is helpful in confirming a diagnosis of pityriasis versicolor.7
Microscopic confirmation is helpful when there is uncertainty about the diagnosis. It is not useful diagnostically after the patient is treated since it will be negative in most cases. Pretreatment diagnosis can be confirmed by microscopic examination of skin scrapings treated with potassium hydroxide or stained with Swartz Lamkin or chlorazol black. Using stains allows for easier identification of fungal forms and can be helpful for clinicians who infrequently examine slides. Alternatively, scrapings can be sent to a laboratory with a request for fungal microscopy. Examination of prepared slides reveals numerous spores and hyphae that resemble “spaghetti and meatballs” (fig 2⇓).
The differential diagnosis for patients presenting with the signs and symptoms suggestive of pityriasis versicolor is broad. Unusual presentations, treatment unresponsive cases, or negative results from microscopic examination of skin scrapings treated with potassium hydroxide should prompt consideration of an alternative diagnosis such as post-inflammatory hyperpigmentation (or hypopigmentation), pityriasis rosea (fig 3⇓), vitiligo, confluent and reticulated papillomatosis (fig 4⇓), or progressive macular hypomelanosis (fig 5⇓). Post-inflammatory hyperpigmentation may resemble pityriasis versicolor but can be distinguished by a history of a preceding inflammatory rash, lack of scale, and a distribution which follows the primary cause. The lesions in vitiligo are easily distinguishable from pityriasis versicolor. The primary lesions of vitiligo are depigmented macules lacking scale. They occur most commonly on the wrists, ankles, genitalia, and face.
Correspondence to: M Bigby [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
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BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 2 of 6
PRACTICE
The bottom line Pityriasis versicolor is a superficial fungal infection of the skin caused by Malassezia species that induces a characteristic rash of well demarcated, thin, scaly plaques that can be hypopigmented, hyperpigmented, or erythematous Diagnosis is usually made clinically, based on characteristic skin lesions and the “evoked scale sign” (when stretching or scraping the skin makes the fine scale of lesions more apparent) Diagnosis is aided by microscopic examination of potassium hydroxide treated or stained skin scrapings, which reveal numerous spores and hyphae First line topical treatments include ketoconazole, selenium sulphide, or zinc pyrithione shampoo. Systemic treatment is limited to use in extensive disease Disease recurrence is common; options for prophylaxis include topical ketoconazole, selenium sulphide, or zinc pyrithione shampoo
Pityriasis rosea may resemble pityriasis versicolor. Pityriasis rosea typically begins with a “herald patch,” a single large, erythematous plaque that has a trailing scale (scale that is inside the outer border of the plaque). Oval plaques with similar trailing scale appear several days after the appearance of the herald patch. Confluent and reticulated papillomatosis presents with hyperpigmented reticulated acanthotic plaques, most commonly on the torso. The plaques are generally thicker than those seen with pityriasis versicolor, microscopic examination of skin scrapings treated with potassium hydroxide is negative, and it is unresponsive to treatments that work for pityriasis versicolor. The diagnosis can be established with a punch biopsy of the affected skin. Progressive macular hypomelanosis presents with hypopigmented macules that do not have scale. It most commonly affects the back, but widespread involvement of the torso is not uncommon. Diagnosis is usually made clinically.
How is pityriasis versicolor treated? Topical treatment
Topical therapy is the treatment of choice for most patients. Topical treatments include imidazole antifungal creams or shampoos (such as ketoconazole), zinc pyrithione shampoo, selenium sulphide shampoo, and sulphur plus salicylic acid shampoo. Randomised control trials for topical treatments show the effectiveness of these treatments compared with placebo, with numbers needed to treat of one to two.8 The strength of evidence is moderate, consisting of small trials of generally low quality that have results of similar magnitude and direction.8 Other less extensively studied topical agents include lactic acid, adapalene, 1% diclofenac gel, and artemisia sieberi lotion.8
The duration of topical treatments in the literature ranges from days to weeks. Studies suggest that longer durations of treatment and increased concentrations of active ingredient lead to improved cure rates.8 A first line recommendation for topical therapy is to apply shampoo containing ketoconazole, selenium sulphide, or zinc pyrithione to affected areas for 5-10 minutes before washing off in the shower (table⇓). This treatment should be repeated daily for one to four weeks. The imidazole creams can be applied once or twice daily for one to four weeks. If the rash does not resolve after treatment with a first line shampoo recommendation, then a different first line agent should be tried. If there is continued lack of response to a second topical treatment, then the patient should be referred to a dermatologist for further management. Topical treatments for pityriasis versicolor are generally well tolerated. The most common adverse effects of these treatments are skin irritation and contact allergy. Selenium sulphide can cause skin irritation and is associated with a strong odour.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Systemic treatment Systemic treatments for pityriasis versicolor are useful for treating extensive skin disease (table⇓). In general, the evidence behind systemic treatment recommendations is of poor quality.8 9 A systematic review found that effective systemic treatments include fluconazole 300 mg per week for two weeks or itraconazole 200 mg daily for five to seven days, with numbers needed to treat of one to two when compared with placebo.9 Similar to topical therapies, data suggest that longer durations of treatment and higher doses produce greater cure rates. Oral ketoconazole should be avoided in the treatment of pityriasis versicolor given its withdrawal from the market in Europe and the US Food and Drug Administration warning that ketoconazole should not be used to treat superficial fungal infections of the skin.10 Systemic therapies are associated with greater side effects. Imidazoles and triazoles (such as fluconazole and itraconazole) inhibit the enzyme cytochrome P450 system, therefore causing drug-drug interactions. These systemic agents should be avoided in patients taking cisapride, astemizole, and terfenadine because of potential rare cardiovascular adverse events. Oral itraconazole has been associated with rare cases of serious hepatotoxicity and congestive heart failure and should be avoided in patients with active liver disease or a history of congestive heart failure. Serious adverse reactions are rare with oral fluconazole.
How can pityriasis versicolor be prevented? Disease recurrence is common and adds to the challenge of treating the disease. Topical or oral treatment options are used for prophylaxis against disease recurrence (table⇓). Topical therapies are indicated for most patients. We recommend topical ketoconazole, zinc pyrithione, or selenium sulphide shampoo applied for 5-10 minutes, one to four times monthly for prophylaxis. Prophylactic treatment with oral agents should be reserved for use in patients with extensive disease recurrence that is refractory to treatment with topical therapies. A six month randomised trial found that prophylactic treatment with oral itraconazole 200 mg twice daily once per month compared with placebo resulted in a greater percentage of patients without disease recurrence with a number needed to treat of four.11 Contributors: All authors contributed to drafting and revising this article and have approved the final version to be published. MB is guarantor. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed.
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BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 3 of 6
PRACTICE
1 2 3 4 5 6 7
Hellgren L, Vincent J. The incidence of tinea versicolor in central Sweden. J Med Microbiol 1983;16:501-2. Szepietowski JC, Baran E, Wild E. Tinea versicolor: a perspective study. Korean J Med Mycol 2000;5:108-12. Kyriakis KP, Palamaras STI, Pagana G, Michailides C, Emmanuelides S. Pityriasis versicolor prevalence by age and gender. Mycoses 2006;49:517-8. Kaymak Y, Taner E. Anxiety and depression in patients with pityriasis rosea compared to patients with tinea versicolor. Dermatol Nurs 2008;20:367-70, 377. Schwartz RA. Superficial fungal infections. Lancet 2004;364:1173-82. Gaitanis G, Magiatis P, Hantschke M, Bassukas ID, Velegraki A. The Malassezia genus in skin and systemic diseases. Clin Microbiol Rev 2012;25:106-41. Han A, Calcara DA, Stoecker WV, Daly J, Siegel DM, Shell A. Evoked scale sign of tinea versicolor. Arch Dermatol 2009;145:1078.
8 9 10 11
Hu SW, Bigby M. Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010;146:1132-40. Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg 2014;18:79-90. US Food and Drug Administration. Drug safety communication: FDA limits usage of Nizoral (ketoconazole) oral tablets due to potentially fatal liver injury and risk of drug interactions and adrenal gland problems. 2013. www.fda.gov/drugs/drugsafety/ucm362415.htm. Faergemann J, Gupta AK, Al Mofadi A, Abanami A, Shareaah AA, Marynissen G. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol 2002;138:69.
Cite this as: BMJ 2015;350:h1394 © BMJ Publishing Group Ltd 2015
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 4 of 6
PRACTICE
Table Table 1| Treatment options for pityriasis versicolor First line Topical treatments Ketoconazole, selenium sulphide, or zinc pyrithione shampoo applied for 5-10 minutes daily for 1-4 weeks Imidazole cream applied once or twice daily for 1-4 weeks
Second line Salicylic acid shampoo Lactic acid cream
Systemic treatments Fluconazole 300 mg/week for 2 weeks
Itraconazole 200 mg/day for 5-7 days
Prophylaxis
Fluconazole 300 mg monthly
Ketoconazole, selenium sulphide, or zinc pyrithione shampoo applied for 5-10 minutes 1-4 times monthly
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BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 5 of 6
PRACTICE
Figures
Fig 1 Pityriasis versicolor is a superficial fungal infection of the skin that causes a characteristic rash of well demarcated, thin scaly plaques that can be hyperpigmented (A). The fine scale of lesions becomes more apparent when the skin is scraped (B)
Fig 2 Examination of a slide prepared with Swartz Lamkin stain reveals numerous spores and hyphae that resemble “spaghetti and meatballs”
Fig 3 Pityriasis rosea typically begins with a “herald patch,” a single large, erythematous plaque (A). Similar oval plaques appear several days after the appearance of the herald patch. The plaques characteristically have a trailing scale (a scale that is inside the outer border of the plaque) (B)
For personal use only: See rights and reprints http://www.bmj.com/permissions
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BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 6 of 6
PRACTICE
Fig 4 Patients with confluent and reticulated papillomatosis present with hyperpigmented, acanthotic plaques, most commonly on the torso. The plaques are generally thicker than those seen in pityriasis versicolor
Fig 5 Progressive macular hypomelanosis presents with hypopigmented macules that do not have scale. It most commonly affects the lower back
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 6
Practice
PRACTICE PRACTICE POINTER
Pityriasis versicolor 1
2
Sruthi Renati , Anthony Cukras , Michael Bigby
2
Harvard Medical School, Boston, Massachusetts, USA; 2Department of Dermatology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA 02215, USA 1
What is pityriasis versicolor? Pityriasis versicolor is a superficial fungal infection of the skin. It is caused by Malassezia, a lipophilic dimorphic fungus. This fungus is part of the normal skin flora but can cause disease when it converts to its pathogenic hyphal form. Certain environmental, genetic, and immunological factors can predispose to this pathogenic conversion and contribute to the development of disease.
The fungus grows best in warm and humid conditions, explaining the higher prevalence of pityriasis versicolor in humid tropical climates. A survey in central Sweden found a 0.5% prevalence of pityriasis versicolor, whereas the prevalence is as high as 50% in tropical countries.1 2 There is a significant increase in disease prevalence between childhood and adolescence, probably due to hormonal changes that increase sebum production and allow for a more lipid-rich environment in which the fungus can grow. The disease is also more common among adolescents and young adults who are physically active.3 Although effective oral and topical treatment options exist, disease recurrence is common and pityriasis versicolor can have an impact on quality of life.4
How does pityriasis versicolor present? Patients with pityriasis versicolor present with a rash consisting of well demarcated, finely scaling, thin plaques (fig 1⇓). These plaques can be hyperpigmented, hypopigmented, or erythematous and occasionally become confluent and widespread. The fine scale present on the lesions becomes more apparent when the affected skin is stretched or scraped (fig 1). The distribution of affected skin is theorised to reflect the lipophilic nature of the fungus and its preference for sebum-rich skin. The rash commonly affects the torso but can be widespread, and the face is particularly affected in children.5 The skin lesions are generally asymptomatic or mildly pruritic but can be severely pruritic in certain humid conditions.6 A concerning feature of the disease is that hyperpigmentation or hypopigmentation associated with the rash often persists for months after the fungal infection is appropriately treated.
How is pityriasis versicolor diagnosed? Pityriasis versicolor can be clinically diagnosed by its characteristic skin lesions (erythematous, hyperpigmented or hypopigmented, finely scaling, thin plaques). The fine scale on the affected skin is not easily seen but becomes more apparent when the skin is stretched or scraped (the “evoked scale sign”). This sign is helpful in confirming a diagnosis of pityriasis versicolor.7
Microscopic confirmation is helpful when there is uncertainty about the diagnosis. It is not useful diagnostically after the patient is treated since it will be negative in most cases. Pretreatment diagnosis can be confirmed by microscopic examination of skin scrapings treated with potassium hydroxide or stained with Swartz Lamkin or chlorazol black. Using stains allows for easier identification of fungal forms and can be helpful for clinicians who infrequently examine slides. Alternatively, scrapings can be sent to a laboratory with a request for fungal microscopy. Examination of prepared slides reveals numerous spores and hyphae that resemble “spaghetti and meatballs” (fig 2⇓).
The differential diagnosis for patients presenting with the signs and symptoms suggestive of pityriasis versicolor is broad. Unusual presentations, treatment unresponsive cases, or negative results from microscopic examination of skin scrapings treated with potassium hydroxide should prompt consideration of an alternative diagnosis such as post-inflammatory hyperpigmentation (or hypopigmentation), pityriasis rosea (fig 3⇓), vitiligo, confluent and reticulated papillomatosis (fig 4⇓), or progressive macular hypomelanosis (fig 5⇓). Post-inflammatory hyperpigmentation may resemble pityriasis versicolor but can be distinguished by a history of a preceding inflammatory rash, lack of scale, and a distribution which follows the primary cause. The lesions in vitiligo are easily distinguishable from pityriasis versicolor. The primary lesions of vitiligo are depigmented macules lacking scale. They occur most commonly on the wrists, ankles, genitalia, and face.
Correspondence to: M Bigby [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 2 of 6
PRACTICE
The bottom line Pityriasis versicolor is a superficial fungal infection of the skin caused by Malassezia species that induces a characteristic rash of well demarcated, thin, scaly plaques that can be hypopigmented, hyperpigmented, or erythematous Diagnosis is usually made clinically, based on characteristic skin lesions and the “evoked scale sign” (when stretching or scraping the skin makes the fine scale of lesions more apparent) Diagnosis is aided by microscopic examination of potassium hydroxide treated or stained skin scrapings, which reveal numerous spores and hyphae First line topical treatments include ketoconazole, selenium sulphide, or zinc pyrithione shampoo. Systemic treatment is limited to use in extensive disease Disease recurrence is common; options for prophylaxis include topical ketoconazole, selenium sulphide, or zinc pyrithione shampoo
Pityriasis rosea may resemble pityriasis versicolor. Pityriasis rosea typically begins with a “herald patch,” a single large, erythematous plaque that has a trailing scale (scale that is inside the outer border of the plaque). Oval plaques with similar trailing scale appear several days after the appearance of the herald patch. Confluent and reticulated papillomatosis presents with hyperpigmented reticulated acanthotic plaques, most commonly on the torso. The plaques are generally thicker than those seen with pityriasis versicolor, microscopic examination of skin scrapings treated with potassium hydroxide is negative, and it is unresponsive to treatments that work for pityriasis versicolor. The diagnosis can be established with a punch biopsy of the affected skin. Progressive macular hypomelanosis presents with hypopigmented macules that do not have scale. It most commonly affects the back, but widespread involvement of the torso is not uncommon. Diagnosis is usually made clinically.
How is pityriasis versicolor treated? Topical treatment
Topical therapy is the treatment of choice for most patients. Topical treatments include imidazole antifungal creams or shampoos (such as ketoconazole), zinc pyrithione shampoo, selenium sulphide shampoo, and sulphur plus salicylic acid shampoo. Randomised control trials for topical treatments show the effectiveness of these treatments compared with placebo, with numbers needed to treat of one to two.8 The strength of evidence is moderate, consisting of small trials of generally low quality that have results of similar magnitude and direction.8 Other less extensively studied topical agents include lactic acid, adapalene, 1% diclofenac gel, and artemisia sieberi lotion.8
The duration of topical treatments in the literature ranges from days to weeks. Studies suggest that longer durations of treatment and increased concentrations of active ingredient lead to improved cure rates.8 A first line recommendation for topical therapy is to apply shampoo containing ketoconazole, selenium sulphide, or zinc pyrithione to affected areas for 5-10 minutes before washing off in the shower (table⇓). This treatment should be repeated daily for one to four weeks. The imidazole creams can be applied once or twice daily for one to four weeks. If the rash does not resolve after treatment with a first line shampoo recommendation, then a different first line agent should be tried. If there is continued lack of response to a second topical treatment, then the patient should be referred to a dermatologist for further management. Topical treatments for pityriasis versicolor are generally well tolerated. The most common adverse effects of these treatments are skin irritation and contact allergy. Selenium sulphide can cause skin irritation and is associated with a strong odour.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Systemic treatment Systemic treatments for pityriasis versicolor are useful for treating extensive skin disease (table⇓). In general, the evidence behind systemic treatment recommendations is of poor quality.8 9 A systematic review found that effective systemic treatments include fluconazole 300 mg per week for two weeks or itraconazole 200 mg daily for five to seven days, with numbers needed to treat of one to two when compared with placebo.9 Similar to topical therapies, data suggest that longer durations of treatment and higher doses produce greater cure rates. Oral ketoconazole should be avoided in the treatment of pityriasis versicolor given its withdrawal from the market in Europe and the US Food and Drug Administration warning that ketoconazole should not be used to treat superficial fungal infections of the skin.10 Systemic therapies are associated with greater side effects. Imidazoles and triazoles (such as fluconazole and itraconazole) inhibit the enzyme cytochrome P450 system, therefore causing drug-drug interactions. These systemic agents should be avoided in patients taking cisapride, astemizole, and terfenadine because of potential rare cardiovascular adverse events. Oral itraconazole has been associated with rare cases of serious hepatotoxicity and congestive heart failure and should be avoided in patients with active liver disease or a history of congestive heart failure. Serious adverse reactions are rare with oral fluconazole.
How can pityriasis versicolor be prevented? Disease recurrence is common and adds to the challenge of treating the disease. Topical or oral treatment options are used for prophylaxis against disease recurrence (table⇓). Topical therapies are indicated for most patients. We recommend topical ketoconazole, zinc pyrithione, or selenium sulphide shampoo applied for 5-10 minutes, one to four times monthly for prophylaxis. Prophylactic treatment with oral agents should be reserved for use in patients with extensive disease recurrence that is refractory to treatment with topical therapies. A six month randomised trial found that prophylactic treatment with oral itraconazole 200 mg twice daily once per month compared with placebo resulted in a greater percentage of patients without disease recurrence with a number needed to treat of four.11 Contributors: All authors contributed to drafting and revising this article and have approved the final version to be published. MB is guarantor. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed.
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 3 of 6
PRACTICE
1 2 3 4 5 6 7
Hellgren L, Vincent J. The incidence of tinea versicolor in central Sweden. J Med Microbiol 1983;16:501-2. Szepietowski JC, Baran E, Wild E. Tinea versicolor: a perspective study. Korean J Med Mycol 2000;5:108-12. Kyriakis KP, Palamaras STI, Pagana G, Michailides C, Emmanuelides S. Pityriasis versicolor prevalence by age and gender. Mycoses 2006;49:517-8. Kaymak Y, Taner E. Anxiety and depression in patients with pityriasis rosea compared to patients with tinea versicolor. Dermatol Nurs 2008;20:367-70, 377. Schwartz RA. Superficial fungal infections. Lancet 2004;364:1173-82. Gaitanis G, Magiatis P, Hantschke M, Bassukas ID, Velegraki A. The Malassezia genus in skin and systemic diseases. Clin Microbiol Rev 2012;25:106-41. Han A, Calcara DA, Stoecker WV, Daly J, Siegel DM, Shell A. Evoked scale sign of tinea versicolor. Arch Dermatol 2009;145:1078.
8 9 10 11
Hu SW, Bigby M. Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010;146:1132-40. Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg 2014;18:79-90. US Food and Drug Administration. Drug safety communication: FDA limits usage of Nizoral (ketoconazole) oral tablets due to potentially fatal liver injury and risk of drug interactions and adrenal gland problems. 2013. www.fda.gov/drugs/drugsafety/ucm362415.htm. Faergemann J, Gupta AK, Al Mofadi A, Abanami A, Shareaah AA, Marynissen G. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol 2002;138:69.
Cite this as: BMJ 2015;350:h1394 © BMJ Publishing Group Ltd 2015
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 4 of 6
PRACTICE
Table Table 1| Treatment options for pityriasis versicolor First line Topical treatments Ketoconazole, selenium sulphide, or zinc pyrithione shampoo applied for 5-10 minutes daily for 1-4 weeks Imidazole cream applied once or twice daily for 1-4 weeks
Second line Salicylic acid shampoo Lactic acid cream
Systemic treatments Fluconazole 300 mg/week for 2 weeks
Itraconazole 200 mg/day for 5-7 days
Prophylaxis
Fluconazole 300 mg monthly
Ketoconazole, selenium sulphide, or zinc pyrithione shampoo applied for 5-10 minutes 1-4 times monthly
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 5 of 6
PRACTICE
Figures
Fig 1 Pityriasis versicolor is a superficial fungal infection of the skin that causes a characteristic rash of well demarcated, thin scaly plaques that can be hyperpigmented (A). The fine scale of lesions becomes more apparent when the skin is scraped (B)
Fig 2 Examination of a slide prepared with Swartz Lamkin stain reveals numerous spores and hyphae that resemble “spaghetti and meatballs”
Fig 3 Pityriasis rosea typically begins with a “herald patch,” a single large, erythematous plaque (A). Similar oval plaques appear several days after the appearance of the herald patch. The plaques characteristically have a trailing scale (a scale that is inside the outer border of the plaque) (B)
For personal use only: See rights and reprints http://www.bmj.com/permissions
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BMJ 2015;350:h1394 doi: 10.1136/bmj.h1394 (Published 7 April 2015)
Page 6 of 6
PRACTICE
Fig 4 Patients with confluent and reticulated papillomatosis present with hyperpigmented, acanthotic plaques, most commonly on the torso. The plaques are generally thicker than those seen in pityriasis versicolor
Fig 5 Progressive macular hypomelanosis presents with hypopigmented macules that do not have scale. It most commonly affects the lower back
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
