Tinea Versicolor Clinical Presentation

Updated: Jun 09, 2020
  • Author: Christopher Sayed, MD; Chief Editor: Dirk M Elston, MD  more...
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Presentation

History

Most individuals with tinea versicolor report cosmetically disturbing, abnormal pigmentation. The involved skin regions are usually the trunk, the back, the abdomen, and the proximal extremities. The face, the scalp, and the genitalia are less commonly involved. In patients with fair skin, the color of each lesion varies from almost white to reddish-brown or fawn colored. In darker skin types, involved areas can have varying degrees of either hypopigmentation or hyperpigmentation. A fine, dustlike scale covers the lesions.

Tinea versicolor patients often report that the involved skin lesions fail to tan in the summer and cause the affected areas to become more apparent. Conversely, affected areas may become subtler in winter months as background tan fades.

Occasionally, a tinea versicolor patient also reports mild pruritus. In most instances, the condition is asymptomatic.

Greater than 20% of tinea versicolor patients report a family history of the condition. This subset of patients records a higher rate of recurrence and longer duration of disease. [25]

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Physical Examination

Although tinea versicolor is often diagnosed by the observation of the classic hypopigmented-tohyperpigmented, centrally coalescing, oval-to-round patches with mild scale, it can occasionally be difficult to distinguish from other dermatoses. The scale on these lesions is not always immediately evident and may require scratching or stretching of the skin surface. [14]

A dermatoscope is also a useful diagnostic tool in examining affected skin. Studies have shown that the most common dermoscopic feature in tinea versicolor lesions are nonuniform pigmentation, scaling, perilesional hyperpigmentation or a contrast halo ring, and folliculocentric lesions. Differences in scaling patterns were observed in hypopigmented and hyperpigmented lesions. [26, 27] In hypopigmented lesions, dermoscopy shows a well-demarcated white area with patchy and diffuse scaling found largely in skin furrows. Hyperpigmented lesions under dermoscopy show fine scale in skin furrows overlying brown pigmentation. [28, 29] Hyperpigmented lesions were found to have more prominent scaling, and the amount of scaling was proposed to correlate with disease activity. [26]

Tinea versicolor can present in four forms in addition to a rare, atrophic form.

Tinea versicolor - Form 1

The most common appearance of the disease is as numerous, well-marginated, finely scaly, oval-to-round macules scattered over the upper trunk, with occasional extension to the lower trunk, neck, and proximal extremities.

The macules tend to coalesce, forming irregularly shaped patches of pigmentary alteration. As the name versicolor implies, the disease characteristically reveals a variance in skin hue. The involved areas can be either darker or lighter than the surrounding skin.

The condition is more noticeable during the summer months when the discrepancy in color from the normal skin becomes more apparent.

Fine, powdery scale may be readily apparent and is uniformly provocable with light scraping of the involved skin with a scalpel blade or the edge of a glass slide. See the image below.

Hyperpigmented macules forming some confluent patc Hyperpigmented macules forming some confluent patches on the abdomen. While scale is not readily apparent, it is easily provoked with light scratching. On dark skin, affected areas may be hypopigmented or hyperpigmented.

Tinea versicolor - Form 2

An inverse form of tinea versicolor also exists in which the condition has an entirely different distribution, affecting the flexural regions, the face, or isolated areas of the extremities. This form has also been reported to appear in intertriginous areas. [30] This form of tinea versicolor is more often seen in hosts who are immunocompromised.

This form of the disease can be confused with candidiasis, seborrheic dermatitis, psoriasis, erythrasma, and dermatophyte infections.

Tinea versicolor - Form 3

The third form of Malassezia infections of the skin involves the hair follicle. This condition is typically localized to the back, the chest, and the extremities. This perifollicular form can present as hypopigmented or hyperpigmented. [31]

This form can be clinically difficult to differentiate from bacterial folliculitis. The presentation of Pityrosporum folliculitis is a perifollicular, erythematous papule or pustule.

Predisposing factors include diabetes, high humidity, steroid or antibiotic therapy, and immunosuppressant therapy. Additionally, several reports reveal that M furfur also plays a role in seborrheic dermatitis.

Tinea versicolor - Form 4

Another clinical presentation is multiple firm, 2- to 3-mm, monomorphic, red-brown, inflammatory papules. These lesions may, or may not also demonstrate a fine white scale.

The lesions are usually found on the torso and are asymptomatic.

Histologically, the rash demonstrates not only fungal hyphae and spores in the stratum corneum, but also an interface dermatitis in the superficial dermis. [32]

Atrophying tinea versicolor

Atrophying tinea versicolor is a rare form that presents as atrophic, ivory-colored–to–erythematous lesions that are oval-to-round in shape. These lesions can have a wrinkled surface, and the atrophy is limited to the areas of skin affected by tinea versicolor. [17, 33]

Histologic features of these lesions include epidermal atrophy, vascular ectasia, and rarefaction of collagen and elastic fibers. [17, 20]

These lesions are often reported in patients who are either misdiagnosed or have a comorbid condition requiring an extended use of topical corticosteroids. [17, 18] However, cases of atrophying tinea versicolor have been described in patients who do not have a history of using topical corticosteroids. [20]

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