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Pediatric Tinea Versicolor Medication

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

Medication Summary

Tinea versicolor responds well to both topical and oral antimycotic therapies. Some patients prefer oral therapy because of convenience, while others prefer the safety of topical therapies. Many effective topical therapies are available without prescription and can be used for suppressive therapy or for treating recurrences without the need for a follow-up visit.

Topical therapy alone is indicated for most patients. Systemic treatment may be indicated for patients with extensive involvement, those with recurrent infections, or those in whom topical therapy has failed.

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Antifungal Agent, Topical

Class Summary

Selenium sulfide is effective against M furfur; it also has cytostatic effects on the epidermis and follicular epithelium, thus reducing corneocyte production. Azole, allylamine and other antifungal creams are also highly effective mycocides against M furfur.

Selenium sulfide topical (Selsun Blue, Exsel, Head & Shoulders)

 

Selenium sulfide is available as a shampoo or lotion in 1% or 2.5% concentrations. It is a safe and effective therapy that has been used for years. The principle advantages of selenium sulfide are its low cost, over-the-counter availability, and convenient application. However, it is an irritant, and some patients report itching or eczema after overnight applications. It may also stain clothes and bedding. Lotion is preferred in children and patients with sensitive skin.

Clotrimazole topical (Lotrimin-AF, Canesten)

 

Clotrimazole is an imidazole broad-spectrum antifungal agent. It inhibits the synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Econazole topical (Ecoza)

 

Econazole is an nntifungal agent that is a water-miscible base consisting of pegoxol 7 stearate, peglicol 5 oleate, mineral oil, benzoic acid, butylated hydroxyanisole, and purified water. The color of the soft cream is white to off-white and is for topical use only. It interferes with RNA and protein synthesis and metabolism. It disrupts fungal cell wall permeability, causing fungal cell death. Econazole exhibits broad-spectrum antifungal activity against many gram-negative organisms. It is effective in cutaneous infections.

Ketoconazole topical (Nizoral)

 

Ketoconazole is an imidazole broad-spectrum antifungal agent. It inhibits the synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Oxiconazole (Oxistat)

 

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

Sertaconazole (Ertaczo)

 

Sertaconazole is an imidazole broad-spectrum antifungal agent. It inhibits the synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Ciclopirox (Batrafen, Loprox)

 

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

Naftifine (Exoderil, Naftin)

 

Naftifine is a broad-spectrum antifungal agent and synthetic allylamine derivative; it may decrease the synthesis of ergosterol, which, in turn, inhibits fungal cell growth.

Terbinafine topical (Lamisil)

 

Terbinafine inhibits squalene epoxidase, which decreases ergosterol synthesis, causing fungal cell death. Use the medication until symptoms significantly improve. The duration of treatment should be greater than 1 week, but not greater than 4 weeks.

Butenafine (Mentax)

 

Butenafine inhibits squalene epoxidation, which, in turn, causes blockage of ergosterol biosynthesis (an essential component of fungal cell membranes). It is used topically for tinea (pityriasis) versicolor due to M furfur, tinea pedis (ie, athlete's foot), tinea corporis (ie, ringworm), and tinea cruris (ie, jock itch) due to Epidermophyton floccosum, Trichophyton mentagrophytes, Trichophyton rubrum, and Trichophyton tonsurans.

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Antifungal Agent, Systemic

Class Summary

Systemic azoles are highly effective against M furfur and are usually combined with topical antimycotics in severe cases.

Ketoconazole oral (Nizoral)

 

Ketoconazole is both a topical and systemic agent. It is an imidazole broad-spectrum antifungal agent; it inhibits the synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death. Ketoconazole 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 younger than 10 years with oral ketoconazole for tinea versicolor.

Fluconazole (Diflucan)

 

Fluconazole is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol, thereby disrupting cellular membranes. It has little affinity for mammalian cytochromes, which is believed to explain its low toxicity. Fluconazole is available as tablets for oral administration, as a powder for oral suspension, and as a sterile solution for intravenous use. It has fewer adverse effects and better tissue distribution than older systemic imidazoles. It is most commonly used in the treatment of candidiasis.

Itraconazole (Sporanox, Orungal)

 

Itraconazole is a synthetic triazole antifungal agent that inhibits fungal cell growth by inhibiting the cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.

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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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