Pityriasis Versicolor

Pityriasis versicolor, also known as tinea versicolor, is a superficial fungal infection of the skin caused by the yeast Malassezia spp. (previously Pityrosporum).

• It is common worldwide, particularly in tropical and subtropical regions.

• The infection is often chronic, recurrent, and typically affects adolescents and young adults.

• Predisposing factors include:

  • Hot and humid climates

  • Excessive sweating (hyperhidrosis)

  • Oily skin

  • Immunosuppression

  • Use of corticosteroids or antibiotics

• Pathophysiology: The yeast alters from a commensal, oval form to a pathogenic mycelial form, leading to scaling and pigmentary changes on the skin.

Signs & Symptoms

• Hypopigmented, hyperpigmented, or erythematous patches

  • Hypopigmented lesions are more common in darker-skinned individuals

  • Hyperpigmented lesions may appear in fair-skinned individuals

• Fine scaling over the lesions, often visible after gentle scraping (positive “cigarette paper” sign)

• Distribution:

  • Trunk: chest, back, shoulders

  • Arms and neck

  • Occasionally face

• Symptoms:

  • Mild pruritus, especially with heat or sweating

  • Cosmetic concern due to patchy discoloration

• Course:

  • Chronic, slowly progressive

  • Recurrences are common, particularly in hot/humid conditions

Diagnostic Criteria

• Confluent hypo- or hyperpigmented macules with fine scaling

• Commonly distributed on chest, back, arms, neck, and sometimes face

• Positive KOH preparation: “spaghetti and meatballs” appearance (short hyphae and spores)

• Wood’s lamp examination: may show yellowish-green fluorescence

• Response to antifungal therapy supports the diagnosis

Investigation

• KOH skin scraping: identifies spores and hyphae under microscopy

• Fungal culture: rarely required, mainly for atypical or resistant cases

• Wood’s lamp examination: may show fluorescence in affected areas

• Consider differential diagnosis:

  • Vitiligo

  • Post-inflammatory hypopigmentation

  • Seborrheic dermatitis

Treatment

Non-Pharmacological Treatment

• Encourage good personal hygiene

• Avoid excessive sweating if possible

• Wear breathable clothing to reduce moisture on the skin

• Regular cleansing with gentle soap

Pharmacological Treatment

Topical Therapy (First-line)

• Clotrimazole cream: apply 12 hourly for 2 weeks

OR

• Miconazole nitrate 2% cream: apply 12 hourly for 2 weeks

OR

• Ketoconazole shampoo: use 3 times per week for 4 weeks (if extensive)

AND

Systemic Therapy (for extensive or refractory cases)

• Fluconazole 300 mg PO stat

OR

• Itraconazole 200 mg PO once daily for 2 weeks

Adjunct Measures

• Daily bathing and gentle exfoliation may enhance penetration of topical antifungals.

• Treatment of coexisting seborrheic dermatitis if present.

Prevention

• Maintain good personal hygiene

• Avoid occlusive clothing in hot/humid environments

• Shower promptly after sweating

• Use antifungal shampoos on the trunk or upper arms if prone to recurrences

• Regular follow-up for recurrent cases, especially in tropical climates