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Pediatric Tinea Versicolor Clinical Presentation

  • Author: Lyubomir A Dourmishev, MD, PhD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Feb 05, 2016
 

History

Questioning the patient with tinea versicolor about skin or systemic diseases, current therapy, and drug allergies provides guidance in selecting an appropriate therapy. The following are factors that may be used to guide therapy:

  • Other diseases, including renal disease, hepatic disease, and endocrine disease (eg, diabetes mellitus)
  • History of HIV or other immunocompromising disorder, which can increase the severity of tinea versicolor
  • Other skin disorders, including personal or family history of atopy or other eczematous conditions
  • Current or recent topical or systemic therapy
  • Drug allergies
  • Seasonal variations in skin color
  • Use of some body oils, which may supply additional nutrients to the M furfur
  • Sweat associated with exercise, which may contribute to disease development and recurrence
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Physical

Lesion characteristics

Skin lesions are either hypopigmented or hyperpigmented maculae in various shapes. Hyperpigmented maculae become hypopigmented after solar irradiation and subsequent tanning, as the name implies.

Lesions are either macules or very superficial plaques with fine scale that may not be evident except upon close examination. Even when scale is not apparent, when the skin is wiped with a wet cloth and scraped for examination, it yields a surprising amount of dirty-brown keratin. If not, the areas of dyschromia may represent residual effects of previously treated tinea versicolor. Occasionally, determining whether the lighter or darker skin is affected is difficult.

Lesions have relatively sharp margins and may be lighter or darker than the normal skin color. The lesions are frequently a light tan color in light-skinned individuals. The color of lesions varies from individual to individual, but each individual's lesions are approximately the same color. Lesions are evenly pigmented. The inflammatory border, relative central clearing, and erythema seen in most fungal infections are lacking.

Small lesions are usually circular or oval. Confluent patches with scattered circular or oval macules around the edges are common. Other lesions may be large enough to cover most of the trunk.

Lesions are usually asymptomatic but may be mildly pruritic. The pruritus is more intense when the patient is excessively warm.

Residual hypopigmentation, without overlying scale, may remain for many months following effective treatment. These areas may become more apparent following sun exposure, causing the patient to incorrectly suspect that the infection has recurred.

Examples of findings in tinea versicolor are shown in the images below.

In patients with lighter skin color, lesions frequ In patients with lighter skin color, lesions frequently are a light tan or salmon color.
Scale is frequently difficult to appreciate upon c Scale is frequently difficult to appreciate upon clinical examination.
This individual developed skin discoloration and m This individual developed skin discoloration and mild itching every summer for the past few years. These patients should be instructed on the prophylactic use of topical therapy.
This superficial plaque of tinea versicolor is loc This superficial plaque of tinea versicolor is located in the right antecubital fossa of an adult. This appearance and distribution is uncommon but not rare. A potassium hydroxide (KOH) preparation confirmed the diagnosis.
Although tinea versicolor is uncommon in children Although tinea versicolor is uncommon in children in temperate climates, when it does occur, it is more likely to be atypical in distribution. This 7-year-old boy had areas of tinea versicolor across the forehead and both temples. He was in good health and lived in Washington state when he was diagnosed.
In some patients, the areas affected by tinea vers In some patients, the areas affected by tinea versicolor are not always obvious. In this patient, the abnormal areas are hypopigmented.
Some patients present with extensive tinea versico Some patients present with extensive tinea versicolor. This patient related that his discoloration had been present for more than 20 years. The light-colored areas on the abdomen are the normal areas of skin. Although topical therapy alone is usually effective, this patient may benefit from initial therapy with oral ketoconazole, followed by selenium sulfide applications in the shower 2-3 times a month.
Significant hyperpigmentation caused by a tinea ve Significant hyperpigmentation caused by a tinea versicolor infection.

Lesion distribution

The upper trunk is most commonly affected, but the lesions often spread to the upper arms, antecubital fossae, neck, abdomen, and popliteal fossae. Lesions in the axillae, groin, thighs, and genitalia are less common.[4] Facial, scalp, and palmar lesions occur in the tropics but are rare in temperate zones

In some patients, tinea versicolor primarily affects the flexural regions, the face or isolated areas of the extremities. This unusual pattern of tinea versicolor is seen more often in immunocompromised hosts and can be confused with candidiasis, seborrheic dermatitis, psoriasis, erythrasma, and dermatophyte infections.

Lesions that are imperceptible or doubtful are more visible using a Wood lamp in a darkened room.

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Causes

M furfur is now the most commonly accepted name for the etiologic agent of tinea versicolor. Thus, P orbiculare, P ovale, and Malassezia ovalis are synonyms .

M furfur is a dimorphic lipophilic organism that is cultured only in media enriched with C12-sized or C14-sized fatty acids. Malassezia is able to exist in both yeast and mycelial forms, with yeast most commonly associated with saprofital form (P ovale). Historically, the name M furfur was used to designate the fungal pathogen of tinea versicolor before it is grown in culture. M furfur is not a dermatophyte, does not grow on dermatophyte test media (DTM), and does not respond to griseofulvin therapy.

With the advent of DNA sequencing, numerous pathogenic and nonpathogenic species were found. Some of them appear to be more common in certain areas of the world, and some are more likely to be pathogenic in one area and not in another. Much of the confusion was resolved with the taxonomic revision in 1996, based on sequencing of the large-subunit rRNA and nuclear DNA of more than 100 isolates of Malassezia species.[2] The genus Malassezia was revised to include 7 species: Malassezia globosa, Malassezia sympodialis, M furfur, Malassezia slooffiae, Malassezia pachydermatis, Malassezia restricta, and Malassezia obtusa. The clinical significance of each of these species is under investigation. A study of the epidemiology of Malassezia yeasts associated with pityriasis (tinea) versicolor in Canada revealed the most frequently isolated species included M sympodialis, M globosa, and M furfur.

One study found M globosa in 97% of patients with tinea versicolor; it was found alone in 60% of cases, was associated with M sympodialis in 29% of cases, and was associated with M slooffiae in 7% of cases.[2] M sympodialis and M slooffiae were found in similar percentages on clinically uninvolved skin of the trunk, whereas M globosa was not isolated at other sites. Thus, some authors suggest that M globosa in its mycelial phase is the causative agent of tinea versicolor.[2, 3]

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Contributor Information and Disclosures
Author

Lyubomir A Dourmishev, MD, PhD Associate Professor, Department of Dermatology and Venereology, Medical University of Sofia, Bulgaria

Lyubomir A Dourmishev, MD, PhD is a member of the following medical societies: European Academy of Dermatology and Venereology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Osteopathic Association

Disclosure: Nothing to disclose.

References
  1. Dourmishev AL. Pityriasis versicolor. Iliev B, Mitov G, Radev M. Infectology. Academic publishing house; 2001. 812-3.

  2. Schmidt A. Malassezia furfur: a fungus belonging to the physiological skin flora and its relevance in skin disorders. Cutis. 1997 Jan. 59(1):21-4. [Medline].

  3. Nakabayashi A, Sei Y, Guillot J. Identification of Malassezia species isolated from patients with seborrhoeic dermatitis, atopic dermatitis, pityriasis versicolor and normal subjects. Med Mycol. 2000 Oct. 38(5):337-41. [Medline].

  4. Day T, Scurry J. Vulvar pityriasis versicolor in an immunocompetent woman. J Low Genit Tract Dis. J Low Genit Tract Dis. 2014 Jul;. 18(3):e71-3. [Medline].

  5. Lodha N, Poojary SA. A Novel Contrast Stain for the Rapid Diagnosis of Pityriasis Versicolor: A Comparison of Chicago Sky Blue 6B Stain, Potassium Hydroxide Mount and Culture. Indian J Dermatol. 2015 Jul-Aug. 60(4):340-4. [Medline]. [Full Text].

  6. Wigger-Alberti W, Elsner P. Fluorescence with Wood's light. Current applications in dermatologic diagnosis, therapy follow-up and prevention. Hautarzt. 1997 Aug. 48(8):523-7. [Medline].

  7. [Guideline] Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: Pityriasis (tinea) versicolor. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol. 1996 Feb. 34(2 Pt 1):287-9. [Medline].

  8. Muhammad N, Kamal M, Islam T, Islam N, Shafiquzzaman M. A study to evaluate the efficacy and safety of oral fluconazole in the treatment of tinea versicolor. Mymensingh Med J. 2009 Jan. 18(1):31-5. [Medline].

  9. Cantrell WC, Elewksi BE. Can pityriasis versicolor be treated with 2% ketoconazole foam?. J Drugs Dermatol. 2014 Jul. 13(7):855-9. [Medline].

  10. Gupta AK, Lyons DC. Pityriasis versicolor: an update on pharmacological treatment options. Expert Opin Pharmacother. 2014 Aug. 15(12):1707-13. [Medline].

  11. 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 Mar-Apr. 18(2):79-90. [Medline].

  12. Abdul Bari MA. Comparison of Superficial Mycosis treatment using Butenafine and Bifonazole nitrate Clinical Efficacy. Glob J Health Sci. 2012 Nov 11. 5(1):150-4. [Medline].

  13. Dehghan M, Akbari N, Alborzi N, Sadani S, Keshtkar AA. Single-dose oral fluconazole versus topical clotrimazole in patients with pityriasis versicolor: A double-blind randomized controlled trial. J Dermatol. 2010 Aug. 37(8):699-702. [Medline]. [Full Text].

  14. Shi VS, Lio PA. Diagnosis of pityriasis versicolor in paediatrics: the evoked scale sign. Arch Dis Child. 2011 Apr. 96(4):392-3. [Medline].

 
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In patients with lighter skin color, lesions frequently are a light tan or salmon color.
Upon potassium hydroxide (KOH) examination, hyphae are visible and grow into strands within clumps of keratinocytes. Thick-walled spores frequently occur in grapelike clumps. Individual spores and short stubby hyphae float in the clear areas between clumps of keratinocytes. Many of the short hyphae are dystrophic.
Scale is frequently difficult to appreciate upon clinical examination.
This individual developed skin discoloration and mild itching every summer for the past few years. These patients should be instructed on the prophylactic use of topical therapy.
This superficial plaque of tinea versicolor is located in the right antecubital fossa of an adult. This appearance and distribution is uncommon but not rare. A potassium hydroxide (KOH) preparation confirmed the diagnosis.
Although tinea versicolor is uncommon in children in temperate climates, when it does occur, it is more likely to be atypical in distribution. This 7-year-old boy had areas of tinea versicolor across the forehead and both temples. He was in good health and lived in Washington state when he was diagnosed.
In some patients, the areas affected by tinea versicolor are not always obvious. In this patient, the abnormal areas are hypopigmented.
Clear adhesive tape can be pressed onto areas of tinea versicolor to collect hyphae and spores. The tape is then lightly pressed onto a glass slide, and a drop of methylene blue is placed at the edge of the tape. The methylene blue is allowed to run under the tape staining Malassezia furfur. The spores and hyphae easily are seen against a background clutter of keratinocytes and glue.
Some patients present with extensive tinea versicolor. This patient related that his discoloration had been present for more than 20 years. The light-colored areas on the abdomen are the normal areas of skin. Although topical therapy alone is usually effective, this patient may benefit from initial therapy with oral ketoconazole, followed by selenium sulfide applications in the shower 2-3 times a month.
Significant hyperpigmentation caused by a tinea versicolor infection.
Confluent and reticulated Gougerot and Carteaud papillomatosis.
Mycelium strands and numerous spores observed on a potassium hydroxide (KOH) preparation of tinea versicolor. This combination is commonly referred to as "spaghetti and meatballs."
 
 
 
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