Pediatric Tinea Versicolor Workup

  • Author: Lyubomir A Dourmishev, MD, PhD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jun 6, 2011
 

Laboratory Studies

The diagnosis of tinea versicolor is usually made based on clinical examination findings; however, the diagnosis is easily confirmed with microscopic examination of scales soaked in 10%-15% potassium hydroxide (KOH). See the images below.

Upon potassium hydroxide (KOH) examination, hyphaeUpon 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. Mycelium strands and numerous spores observed on aMycelium strands and numerous spores observed on a potassium hydroxide (KOH) preparation of tinea versicolor. This combination is commonly referred to as "spaghetti and meatballs."
  • Microscopic examination
    • Microscopic examination demonstrates the characteristic thick-walled spherical or oval yeast forms and coarse septate mycelium, often broken up into short filaments.
    • This combination of mycelium strands and numerous spores is commonly referred to as "spaghetti and meatballs."
    • Liquid blue ink, methylene blue, or Swartz-Medrik stain can be added to the KOH preparation for better visualization of the causative organism.
    • Scales may also be removed using clear adhesive tape; they are then directly examined. The tape must be clear and is pressed several times over involved areas of skin. The tape is then lightly pressed, sticky side down, onto a microscope slide. A small drop of methylene blue or other appropriate stain is placed at the edge of the tape and allowed to run between the tape and the glass slide. Spores, often in grapelike clumps, and mycelium are easily seen. See the image below. Clear adhesive tape can be pressed onto areas of tClear 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.
  • Cultures
    • M furfur is a dimorphic lipophilic organism, which is cultured only in media enriched with C12-sized to C14-sized fatty acids. It is not a dermatophyte, does not grow on DTM, and does not respond to griseofulvin therapy.
    • If inoculated into lipid-rich media, the scales of tinea versicolor show spherical yeasts that produce the mycelial phase of the normal flora yeast P orbiculare. Scales that show mycelium and clusters of oval yeasts on direct microscopy grow P ovale on culture.
    • Colonization by M furfur is especially dense in the scalp, the upper trunk, and the flexures. In patients with clinical disease, the organism occurs in both the filamentous (hyphal) and the yeast (spore) stage forms.
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Imaging Studies

  • The disease does not require any imaging studies.
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Other Tests

  • Wood lamp evaluation: Pityriasis versicolor showes blue-green fluorescence of macular dyschromic lesions if irradiated by ultraviolet light with wavelength of approximately 365 nm (black light). However, the test findings may be negative in individuals on antimycotic therapy of those who have recently showered because the fluorescent is water soluble.
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Histologic Findings

  • The characteristic histological changes include hyperkeratosis, parakeratosis, and slight acanthosis with a mild perivascular inflammatory infiltrate in the upper dermis. The organism is usually present in the upper layers of the stratum corneum, and electron microscopy reveals invasion between and within the keratinized cells.
  • M furfur is detected by hematoxylin and eosin (H and E) stain alone, although periodic acid-Schiff (PAS) or methenamine-silver staining facilitates detection.
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Staging

Different rare clinical forms have been described as follows:

  • Papulous variant
  • Erythematous and papulous variant in children
  • Tinea versicolor with atypical localization on face
  • Tinea versicolor with atypical localization on wrists
  • Pityriasis versicolor alba
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Contributor Information and Disclosures
Author

Lyubomir A Dourmishev, MD, PhD  Assistant Professor, Department of Dermatology, Medical University, Alexander's University Hospital, 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

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, and American Osteopathic Association

Disclosure: Nothing to disclose.

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, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-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.

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.

References

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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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