Tinea Versicolor

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Pityrosporum Folliculitis

This scaling disorder with multiple guttate patches is caused by infection of the stratum cornium with the organism Malasezia furfur. The therapeutic strategy is killing the infectious agent with antifungal therapy. Keratolytics can be of benefit. Because the disease often recurs, preventive treatment is often appropriate.

First Steps

1. Shampoos that contain selenium sulfide, zinc pyrithione, or ketoconazole are the most economical therapy and many treatment schedules are effective. Have the patient apply the shampoo to wet skin from the neck to the waist at bedtime, let it dry, and sleep with it on overnight. In the morning the shampoo is showered off and the scalp (and beard) are shampooed for 5 minutes with the same shampoo.
2. Oral ketoconazole is very effective and may be used alone or in addition to the above treatment. Several treatment schedules are effective. Give the patient 2 tablets (400 mg) to be taken at one time. The patient exercises 20-30 minutes after taking the tablets to the point of sweating. The sweat is allowed to dry on the skin and is washed off after at least 8 hours.

Alternative Steps

1. Shampoos containing selenium sulfide, zinc pyrithione, or sulfur and salicylic acid may be applied for 10-20 minutes/day followed by a shampooing. Treatment should occur for 2 weeks.
2. Oral ketaconazole 200 mg at bedtime for 2 weeks is very effective.
3. Benzoyl peroxide 5%-10% once daily for 1 month may be used.
4. Sodium thiosulfate 25%-30% solution twice daily for 4-6 weeks.
5. Itraconazole 400 mg as a single dose. Fluconazole 600 mg as a single dose is an alternative.

Subsequent Steps

1. Although many treatment regimens clear the condition, reappearance of the infection is extremely common especially during the warm seasons or in tropical climates. For this reason all patients are instructed on prophylactic measures, which include the following:
   a. Oral ketoconazole 400 mg once every month, and;
   b. Weekly shampooing of the trunk and scalp with ketoconazole shampoo, or;
   c. Once-monthly application of the above-mentioned shampoos overnight or for 30 minutes before showering.
   These are used year around by those who regularly exercise and during the warm months only by others.
2. Postinfection hypo- or hyperpigmentation is common. Inform patients that this will resolve over several months after adequate treatment.

Pitfalls

1. Oral ketaconazole is rarely associated with hepatotoxicity. It should not be routinely used in those with known liver disease. Liver function tests should be monitored in patients using any regimen other than single day treatment.
2. Men should be informed of the potential of reversible decreased libido.

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