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. Traditional topical herbal therapies are still used in many parts of the world. [15]
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.
Systemic azoles are highly effective against M furfur and are usually combined with topical antimycotics in severe cases, and new agents are being investigated. [16] While oral fluconazole has been used in tinea versicolor, the results may be no better than with topical agents. [17, 18]
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 antifungal 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.
Antifungal Agent, Systemic
Class Summary
Systemic azoles are highly effective against M furfur and are usually combined with topical antimycotics in severe cases, and new agents are being investigated.
Ketoconazole oral (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. While available as both a topical and systemic agent, systemic use of the drug carries a black box warning and is inappropriate for conditions that are not severe or life-threatening. M furfur is eradicated by the presence of ketoconazole in outer skin layers.
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. While it has been used in tinea versicolor, the results may be no better than with topical agents.
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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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."
