eMedicine Specialties > Dermatology > Fungal Infections

Tinea Versicolor: Treatment & Medication

Author: Craig G Burkhart, MD, MPH, Clinical Professor, Department of Medicine, Section of Dermatology, The University of Toledo College of Medicine; Clinical Assistant Professor, Department of Dermatology, Ohio State University College of Medicine
Coauthor(s): Lorie Gottwald, MD, Chief, Division of Dermatology, Associate Professor, Department of Internal Medicine, Medical College of Ohio at Toledo; Craig N Burkhart, MD, MSBS, Assistant Professor, Department of Dermatology, University of North Carolina at Chapel Hill
Contributor Information and Disclosures

Updated: Sep 25, 2009

Treatment

Medical Care

Patients should be informed that tinea versicolor is caused by a fungus that is normally present on the skin surface and is therefore not considered contagious. The condition does not leave any permanent scar or pigmentary changes, and any skin color alterations resolve within 1-2 months after treatment has been initiated. Recurrence is common, and prophylactic therapy may help reduce the high rate of recurrence.

  • Tinea versicolor can be successfully treated with various agents. Effective topical agents include selenium sulfide, sodium sulfacetamide, ciclopiroxolamine,14 as well as azole and allylamine antifungals.15,16,17 Various regimens can be used. Selenium sulfide lotion is liberally applied to affected areas of the skin daily for 2 weeks; each application is allowed to remain on the skin for at least 10 minutes prior to being washed off. In resistant cases, overnight application can be helpful. Topical azole antifungals can be applied every night for 2 weeks. Weekly application of any of the topical agents for the following few months may help prevent recurrence. In patients with widespread disease, topical antifungal therapy can be expensive. Topical allylamines have been demonstrated to be clinically and mycologically effective.
  • Oral therapy is also effective for tinea versicolor and is often preferred by patients because it is more convenient and less time consuming. Of course, oral therapy can be used in consort with topical regimens. Ketoconazole, fluconazole, and itraconazole are the preferred oral agents.18,19,20 Various dosing regimens have been used. With ketoconazole, a 10-day 200-mg daily therapy and as a single-dose 400-mg treatment are popular, both with comparable results.21 Fluconazole has been offered as a single 150- to 300-mg weekly dose for 2-4 weeks. Itraconazole is usually given at 200 mg/d for 7 days.
  • Oral therapy does not prevent the high rate of recurrence, and treatment with oral ketoconazole or a topical agent may need to be repeated intermittently throughout the year. Because tinea versicolor is a benign condition and oral therapy is not without risk, the decision to treat with an oral agent should be made only after a complete discussion of the risks involved.22 In the case of oral terbinafine, some subgroups of M furfur apparently are not clinically responsive, although in vitro studies suggest fungistatic activity.23 Also, a regimen of 1 tablet a month of ketoconazole, fluconazole, and itraconazole has been used successfully to prophylactically prevent recurrences.24

Surgical Care

Reports describe successful treatment of tinea versicolor with 5-aminolevulinic acid photodynamic therapy.25

Diet

Dietary alterations have not proved successful in the treatment of tinea versicolor.

Medication

Tinea versicolor responds well to both topical and oral antimycotic therapies. Many patients prefer oral therapy because of its convenience.

Antifungals

Topical antifungals temporarily eradicate the condition, although treatment may need to be intermittently repeated to prevent recurrence. Oral therapy for tinea versicolor is convenient and effective, but it does not prevent recurrences. A once-monthly (for 6 mo) oral dose of fluconazole is a popular alternative.


Terbinafine (Lamisil)

Inhibits squalene epoxidase, which decreases ergosterol synthesis, causing fungal cell death. Use medication until symptoms significantly improve. Duration of treatment should be >1 wk but not >4 wk.

Adult

Apply bid 1-4 wk

Pediatric

<12 years: Not established
>12 years: Apply as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Discontinue use if sensitivity or irritation occurs; for external use only; avoid contact with eyes


Clotrimazole (Mycelex, Lotrimin-AF)

Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death. Reevaluate diagnosis if no clinical improvement after 4 wk.

Adult

Gently massage into affected area and surrounding skin areas bid for 2-6 wk

Pediatric

Children: Not established
Adolescents: Apply as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For external use only; avoid contact with eyes; if irritation or sensitivity develops, discontinue use


Ketoconazole (Nizoral)

Both topical and systemic agent. Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death. Achieves excellent skin levels with minimal oral dosing. M furfur is eradicated by the presence of ketoconazole in outer skin layers. Tinea versicolor is extremely rare in small children; thus, do not treat children aged <10 y with oral ketoconazole for tinea versicolor.

Adult

Topical: Rub gently into affected area qd/bid for 2-4 wk
Oral: 400 mg PO once; alternatively, 200-mg dosing for 10 d

Pediatric

Topical: Apply as in adults
Oral: 3.3-6.6 mg/kg/d PO

Isoniazid may decrease bioavailability; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dosage can be adjusted); may decrease theophylline levels; inhibition of cytochrome P450 3A4–mediated metabolism of coadministered medications (associated with QT prolongation; therefore, caution with concurrent use of drugs that can prolong the QT interval)
As a CYP3A4 inhibitor (P450 metabolism), many drugs have interactions when coadministered with this medication; advise checking for possible interactions when considering adding this to other medications a patient may be starting or already taking

Documented hypersensitivity; fungal meningitis; concurrent use with astemizole, terfenadine, cisapride, or oral triazolam

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hepatotoxicity may occur; may reversibly decrease corticosteroid serum levels (adverse effects avoided with dose of 200-400 mg/d); administer antacid, anticholinergics, or H2 blockers at least 2 h after taking oral ketoconazole; if sensitivity or irritation develops with topical formulation, discontinue use; topical form is for external use only; avoid contact with eyes; caution in achlorhydria (reduces absorption); considered unsafe in persons with acute porphyrias (adrenal suppression, gynecomastia, hypocholesterolemia, and hypothyroidism have been cause by the administration of ketoconazole)


Ciclopirox (Loprox)

Interferes with synthesis of DNA, RNA, and protein by inhibiting the transport of essential elements in fungal cells.

Adult

Massage into affected areas bid; reevaluate the diagnosis if no improvement after 4 wk

Pediatric

<10 years: Not established
>10 years: Apply as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Avoid contact with eyes and other internal routes


Butenafine (Mentax)

Damages fungal cell membranes causing fungal cell growth to arrest.

Adult

Apply qd for 4 wk

Pediatric

<12 years: Not established
>12 years: Apply as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use topically (not for use in eyes, vagina, or other internal routes)


Naftifine (Naftin)

Broad-spectrum antifungal agent and synthetic allylamine derivative; may decrease the synthesis of ergosterol, which, in turn, inhibits fungal cell growth. If no clinical improvement after 4 wk, reevaluate the patient.

Adult

Gently massage (cream/gel) sparingly into affected area and surrounding skin qd for 2-4 wk

Pediatric

Apply as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Discontinue use if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes


Econazole (Spectazole)

Effective in cutaneous infections. Interferes with RNA and protein synthesis and metabolism. Disrupts fungal cell wall membrane permeability, causing fungal cell death.

Adult

Apply sparingly over affected areas qd/bid

Pediatric

Apply as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes


Oxiconazole (Oxistat)

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out and resulting in fungal cell death.

Adult

Apply to affected area qid

Pediatric

Apply as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

If sensitivity or chemical irritation occurs, discontinue use; for external use only; avoid contact with eyes

More on Tinea Versicolor

Overview: Tinea Versicolor
Differential Diagnoses & Workup: Tinea Versicolor
Treatment & Medication: Tinea Versicolor
Follow-up: Tinea Versicolor
References
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References

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Further Reading

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Keywords

tinea versicolor, pityriasis versicolor, chromophytosis, dermatomycosis furfuracea, tinea flava, aeromia parasitica, Kleinenflechte, Hodi-Potsy, cutaneous fungal infection, hypopigmented macules, hyperpigmented macules, Malassezia furfur, , Pityrosporon orbiculare, Pityrosporon ovale, Malassezia ovalis, Cushing disease

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Contributor Information and Disclosures

Author

Craig G Burkhart, MD, MPH, Clinical Professor, Department of Medicine, Section of Dermatology, The University of Toledo College of Medicine; Clinical Assistant Professor, Department of Dermatology, Ohio State University College of Medicine
Craig G Burkhart, MD, MPH is a member of the following medical societies: American Academy of Dermatology, Ohio State Medical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Lorie Gottwald, MD, Chief, Division of Dermatology, Associate Professor, Department of Internal Medicine, Medical College of Ohio at Toledo
Lorie Gottwald, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Medical Association, American Medical Student Association/Foundation, and American Medical Women's Association
Disclosure: Nothing to disclose.

Craig N Burkhart, MD, MSBS, Assistant Professor, Department of Dermatology, University of North Carolina at Chapel Hill
Craig N Burkhart, MD, MSBS is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Kathryn Schwarzenberger, MD, Associate Professor of Medicine, Division of Dermatology, University of Vermont College of Medicine; Consulting Staff, Division of Dermatology, Fletcher Allen Health Care
Kathryn Schwarzenberger, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, American Dermatological Association, Dermatology Foundation, Medical Dermatology Society, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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