eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Tinea Versicolor: Treatment & Medication

Author: Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine
Contributor Information and Disclosures

Updated: Aug 5, 2009

Treatment

Medical Care

Tinea versicolor is easily treated, and skin color alterations usually resolve within a few months of treatment.3 It does not leave any permanent scars or pigment changes.

Topical therapy alone is indicated for most patients. Systemic treatment is indicated for extensive involvement, for recurrent infections, or when topical therapy has failed. Because treatment is relatively easy and recurrence is common, therapy must be as safe, inexpensive, and convenient as possible. A plan for prophylactic therapy should be discussed with all patients to reduce the high recurrence rate.

Although this relatively benign disorder can be treated easily and cheaply, more than 300 articles regarding tinea versicolor have appeared in recent medical literature. Many of the newer antifungal products are effective against M furfur; however, justifying the cost or risk associated with many of these medications is difficult.

Remember that tinea versicolor does not respond to griseofulvin.

  • Topical agents
    • Effective topical agents include selenium sulfide (eg, Selsun shampoo), azole antimycotics, ciclopirox olamine, piroctone-olamine, zinc pyrithione, propylene glycol lotions, benzoyl peroxide, sodium sulfacetamide, and allylamine antifungals. Treatment with selenium sulfide may result in irritant dermatitis. Patients may require emollient or mild topical steroid application for a few days following therapy.
    • The topical azole antifungals work well, but combinations of compounds do not offer significantly different results. Topical azole and allylamine antifungals are applied every other night for 2 weeks. The weekly application of any of the topical agents for the following few months may help prevent recurrence. The main problem with the use of azole antifungals in tinea versicolor is the inconvenience of applying creams to a wide body surface area. The shampoo form of the antifungal can be used for extensive disease.
    • Selenium sulfide shampoo (eg, Selsun) is also a good prophylactic therapy when applied for a few minutes in the shower once or twice a month.
  • Oral therapy
    • Some patients prefer oral therapy. In adolescents and adults, a single dose of oral ketoconazole (400 mg) is very effective. Having the patient take the ketoconazole with an acidic drink (eg, orange juice, cola) to improve absorption may enhance this therapy. The patient should wait an hour after ingestion and then exercise to the point of sweating. The patient then cools off, allowing the perspiration to dry on the skin, and showers after a few hours.
    • Oral therapy does not prevent the high recurrence rate, and treatment with oral ketoconazole may need to be repeated intermittently throughout the year. Oral itraconazole and fluconazole have also been proven effective but are rarely required.4 Some subgroups of M furfur are apparently not clinically responsive to oral terbinafine. Griseofulvin is not an effective therapy for tinea versicolor.
  • Combination: Various regimens involve both topical and oral therapies. The most common is varying regimens of selenium sulfide shampoo or lotion and oral therapy with ketoconazole.

Activity

  • Activity limitations are not necessary. However, active patients who excessively perspire are more likely to develop recurrences.

Medication

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.

Topical selenium sulfide products

Selenium sulfide is effective at killing M furfur, the primary cause of tinea versicolor. These agents have cytostatic effects on the epidermis and follicular epithelium, thus reducing corneocyte production.


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

Available as 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, OTC 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.

Adult

Applied directly and left on the skin for varying lengths of time; may be applied daily after the shower, left on a few min, then rinsed off
Alternatively, it can be applied to the skin at bedtime and left to dry, then rinsed off the following morning
One overnight application is usually curative, but shorter applications should be continued for 2 wk
Good prophylactic therapy when applied for a few min in the shower 1-2 times/mo

Pediatric

Therapy is similar to that given adults
Application times should not exceed a few min in infants; lotion is preferable for individuals with sensitive skin or in children for whom the shampoo may be irritating

Documented hypersensitivity; significant preexisting skin irritation in the area of tinea versicolor

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

To avoid systemic toxicity, do not use in broken/open skin; caution in significant preexisting skin irritation (may not tolerate therapy); for external use only; avoid contact with eyes

Antifungals, topical

Antifungal creams are effective at killing M furfur, the primary cause of tinea versicolor.


OTC and prescription creams

OTC products include clotrimazole (Lotrimin-AF) and ketoconazole (Nizoral) creams. Prescription alternatives for tinea versicolor include ketoconazole (Nizoral shampoo), ciclopirox (Loprox), butenafine (Mentax), naftifine (Naftin), econazole (Spectazole), oxiconazole (Oxistat), and sulconazole (Exelderm).

Adult

Applied every other night for 2 wk; then qwk for the following few mo should help prevent recurrence

Pediatric

Administer as in adults

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

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

Antifungals, oral

These agents are effective at killing M furfur, the primary cause of tinea versicolor. The major exceptions are griseofulvin and terbinafine, which are not effective.


Ketoconazole (Nizoral)

Fungistatic activity. Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death. This drug achieves excellent skin levels with minimal dosing. M furfur is eradicated by the presence of ketoconazole in the outer skin layers.

Adult

400 mg PO as a single dose; many other dosage regimens also noted

Pediatric

>10 years: 3.3-6.6 mg/kg/d PO qd
Tinea versicolor is extremely rare in small children; thus, do not treat children <10 y with PO ketoconazole

Isoniazid may decrease bioavailability of ketoconazole; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids
Potent inhibitor of CYP450 3A4, decreases elimination and increases toxicity of 3A4 substrates (eg, cyclosporine, terfenadine, astemizole, cisapride, triazolam)

Documented hypersensitivity; fungal meningitis

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

Patients who are at increased risk for preexisting hepatic dysfunction need assessment before usage; routine evaluation of hepatic function before therapy is seldom warranted in a young healthy population
May lower serum testosterone levels, but the short course of therapy required for tinea versicolor is unlikely to significantly affect testosterone levels; may inhibit ACTH secretion when used at therapeutic doses

More on Tinea Versicolor

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

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Further Reading

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Keywords

tinea versicolor, Malassezia furfur, M furfur, Malassezia globosa, M globosa, Malassezia sympodialis, M sympodialis, Malassezia slooffiae, M slooffiae, Malassezia ovalis, M ovalis, Pityrosporum orbiculare, P orbiculare, Pityrosporum ovale, P ovale, chromophytosis, dermatomycosis furfuracea, pityriasis versicolor, tinea flava, Cushing syndrome, malnutrition, atopic dermatitis, diabetes mellitus, HIV, drug allergies, treatment, diagnosis

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Contributor Information and Disclosures

Author

Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine
Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; 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, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
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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