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:
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Other diseases, including renal disease, hepatic disease, and endocrine disease (eg, diabetes mellitus)
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History of HIV or other immunocompromising disorder, which can increase the severity of tinea versicolor
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Other skin disorders, including personal or family history of atopy or other eczematous conditions
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Current or recent topical or systemic therapy
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Drug allergies
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Seasonal variations in skin color
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Use of some body oils, which may supply additional nutrients to the M furfur
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Sweat associated with exercise, which may contribute to disease development and recurrence
Physical Examination
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. In some cases, lesions may appear atrophic (atrophying pityriasis versicolor). [5]
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 frequently are a light tan or salmon color.
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.
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.
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. [6] 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.
Complications
The disease has benign course; however, it tends to have recurrences that must be properly treated. Some patients report for itching, burning and irritation of lesions. Severe depigmentation may cause significant psychological discomfort.
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In patients with lighter skin color, lesions frequently are a light tan or salmon color.
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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.
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Scale is frequently difficult to appreciate upon clinical examination.
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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.
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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.
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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.
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In some patients, the areas affected by tinea versicolor are not always obvious. In this patient, the abnormal areas are hypopigmented.
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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.
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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.
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Significant hyperpigmentation caused by a tinea versicolor infection.
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Confluent and reticulated Gougerot and Carteaud papillomatosis.
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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."
