Review

Pityriasis versicolor: an update on

pharmacological treatment
options
1. Introduction
Aditya K Gupta† & Danika CA Lyons
2. Topical treatments for PV †
Mediprobe Research, Inc., Ontario, Canada
3. Systemic (oral) treatments
for PV Introduction: Pityriasis versicolor (PV) is a superficial fungal infection caused
4. Systematic reviews of drug by Malassezia species; a yeast that naturally colonizes on the skins surface.
efficacy and dosing regimens High efficacy rates are generally obtained with both topical and systemic
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by University of Toronto on 08/11/14

5. Conclusion treatments. However, recurrence rates following successful treatment remain

high and there are no dosage guidelines available for administration of
6. Expert opinion
systemic antifungal agents that carry risks of adverse events.
Areas covered: This review focused on providing an overview of existing
treatments for PV and an introduction to new treatments. A literature search
was conducted using the search strategy, pityriasis versicolor OR tinea
versicolor. Over the past decade, few new treatments have been introduced,
but the efficacy and the dosing regimens of existing treatments have been
systematically reviewed. The results of these reviews are discussed.
Expert opinion: Existing topical and systemic agents are both effective
treatments against PV. Previous dosage recommendations for systemic agents
For personal use only.

have been modified based on recent evidence elucidated in systematic

reviews. However, the absence of standardized collection and reporting
practices in clinical trials precludes any conclusions to be drawn regarding
the efficacy and safety of topical and systemic agents in comparison or in
concert with each other.

Keywords: pityriasis versicolor, systemic antifungal, tinea versicolor, topical antifungal, treatment

Expert Opin. Pharmacother. (2014) 15(12):1707-1713

1. Introduction

Pityriasis versicolor (PV), otherwise known as tinea versicolor, is an innocuous

superficial fungal infection of the skin that primarily affects the face, neck, upper
arms and trunk [1]. It is caused by Malassezia species (M. spp), a genus of lipophilic
fungi naturally colonized on the skin’s surface [2]. However, M. spp is only etiolog-
ical when converted from yeast into its’ rounded, mycelial form [1,2]. The mycelial
form of M. spp is expressed in the edges of lesions characteristic of PV. Lesions
typically present as hypo- or hyper-pigmented, round, flaky patches that may
coalesce in severe cases into larger, irregularly shaped patches [1,3].
Predisposing factors for PV include: genetic predisposition, immunodeficiency,
oily skin, malnutrition, hyperhidrosis, sun exposure, exposure to high temperatures
and humidity, increased plasma cortisol levels, and use of oral contraceptives [3-5].
Indeed, PV is more common in tropical climates than in temperate climates and
primarily affects adults and adolescents [5,6]. Furthermore, lesions typically present
on bodily regions rife with sebaceous glands known to increase oils on the skin’s
surface [3].
Clinical presentation and bright yellow or gold-colored fluorescence under a
Wood’s light (WL) are indicative of PV. However, diagnosis of PV can only be
confirmed through positive mycological examination and/or a positive potassium
hydroxide (KOH) test [1]. Where PV has been identified, topical antifungals are

10.1517/14656566.2014.931373 © 2014 Informa UK, Ltd. ISSN 1465-6566, e-ISSN 1744-7666 1707
All rights reserved: reproduction in whole or in part not permitted
 A. K. Gupta & D. C. A. Lyons
Article highlights.
. Both topical and oral treatments for pityriasis versicolor
are effective although relapse rates remain high.
. 1% ketoconazole foam (only new topical agent
introduced since 2005) appears as effective as 2%
ketoconazole cream; combination therapy with 2%
ketoconazole cream and 0.1% adapalene gel may be
superior to monotherapy with 2% ketoconazole cream.
. Oral ketoconazole (once first line of systemic treatment)
no longer approved for superficial fungal infections in
Canada, US and UK.
.
Itraconazole appears equally effective when
administered at 200 mg/day over 5 or 7 days.
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by University of Toronto on 08/11/14
. Fluconazole appears most effective when administered
in 300 mg dosages over 2 or 4 weeks.
. Pramiconazole (only new oral agent introduced since
2005) appears most effective at 200 mg/day over
2 -- 3 days but may be associated with many adverse
side effects.
This box summarizes key points contained in the article.
the first line of treatment followed by systemic antifungals in
recalcitrant and/or severe cases. While a number of topical
and systemic agents have demonstrated efficacy and safety in
treating PV [7], 60 -- 80% of patients experience recurrence
For personal use only.
of symptoms within 2 years of treatment [6].
In 2005, Gupta et al. presented an extensive review of all
topical and systemic treatments available for the management
of PV [3]. The authors concluded that the large majority of
treatments are effective when used appropriately, some
producing greater long-term remission than others, but none
remedying the chronicity of the disease [3]. The aim of the
current review is to provide an update on emerging pharma-
cological treatments for PV and on new research indicating
the optimal dosing regimens for well-established treatments.
2. Topical treatments for PV
The efficacy and safety of topical agents, including lotions,
shampoos, creams, gels and solutions, are well established as
effective treatments against PV. Existing topical treatments
include nonspecific antifungal agents that primarily remove
dead tissue and prevent further invasion, and specific antifun-
gal agents that have direct fungistatic or fungicidal effects (see
Gupta 2005 for thorough overview of topical treatments) [1,3].
Occasional skin irritation and laborious courses of treatment
(multiple applications over days, weeks or months) associated
with topical agents may result in poor patient compliance.
Patient compliance may be further hindered by recurrence
of signs and symptoms following successful treatment.
Ketoconazole foam appears to be the only new topical
treatment that has undergone evaluation in clinical trials since
2005. Ketoconazole foam is a new formulation of a specific
topical antifungal agent that penetrates transcutaneous tissue
with 6 times greater penetration than lotion formulations [8].
1708 Expert Opin. Pharmacother. (2014) 15(12)
The product is temperature-activated; it melts and evaporates
promptly allowing the active compound to penetrate into the
tissue quickly [8].
In 2008, Di Fonzo et al. compared 1% ketoconazole foam
with 2% ketoconazole cream, the standard treatment against
PV [8]. Forty-six participants with PV diagnosed through
positive WL and mycological examination, were treated with
1% ketoconazole foam or 2% ketoconazole cream once daily
for 14 days. The patients were evaluated at weeks 1, 2 and 5,
and at 3 months. Complete resolution was defined as, absence
of all clinical symptoms based on global clinical scale, a nega-
tive WL evaluation and negative mycological evaluation. The
two groups demonstrated similar efficacy and safety with no
statistically significant differences evident between the groups.
Specifically, at week 5, 29% of the participants in the ketoco-
nazole foam group and 47% in the ketoconazole cream group
achieved complete resolution. At 3 months, 82% of the keto-
conazole foam and 92% of the ketoconazole cream group
achieved complete resolution. Urticaria was reported by one
patient in the ketoconazole cream group; no adverse events
reported in the ketoconazole foam group [8].
Shi et al. recently compared ketoconazole cream as a mono-
therapy with ketoconazole cream in combination with 1%
adapalene gel [9]. Adapalene gel is a naphthoic acid derivative
typically used in the treatment of acne vulgaris [10]. It binds
to retinoic acid receptors (RAR) primarily located in the skin
and epidermis (RARb and RARg, respectively) inhibiting cell
differentiation [10]. One-hundred participants with PV
confirmed by direct microscopy were randomly assigned to
receive 2% ketoconazole cream and 1% adapalene gel once a
day for 2 weeks (Group 1) or 2% ketoconazole cream twice
daily for 2 weeks (Group 2). Total improvement rate was
defined as negative direct microscopy alongside ‡ 50% clinical
improvement 4 weeks after treatment initiation [9]. Group
1 demonstrated a significantly greater total improvement rate
than Group 2 when evaluated at one (38 vs 6%; p = 0.000),
two (88 vs 56%; p = 0.000) and 4 weeks (92 vs 72%;
p = 0.0009) [9]. There were no serious adverse events reported;
minor adverse events included erythema, skin dryness and
burning with combination therapy and mild irritation with
monotherapy.
Thus, 1% ketoconazole foam may represent an alternative
to ketoconazole cream. It appears to be equally effective with
minimal side effects, less residue and improved cutaneous
penetration. Additionally, combination therapy with ketoco-
nazole cream and adapalene gel may offer a faster acting and
more effective treatment option than monotherapy with
ketoconazole cream. This may facilitate patient compliance
as combination therapy.
3. Systemic (oral) treatments for PV
The efficacy of systemic (oral) agents such as ketoconazole, itra-
conazole and fluconazole has been well established. Although
oral terbinafine is an effective treatment for a number of

superficial fungal infections, it is not effective as a treatment
against PV [11]. Orals are on rare occasions, associated with
severe adverse events; thus, they are typically viewed as a second
line of treatment for PV in the event of severe or recalcitrant
cases.
3.1 Ketoconazole
Ketoconazole is an imidazole antifungal used to treat PV; it
acts as a broad-spectrum antifungal by inhibiting 14-a-
demethylation of lanosterol, thereby interfering with ergos-
terol biosynthesis in the cell wall [12]. Once the oral treatment
of choice against PV, oral ketoconazole is no longer approved
for use on superficial fungal infections in Canada [13,14], the
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by University of Toronto on 08/11/14
US [12] or Europe [15] due to the risk of hepatotoxic side effects
associated with it. Newer oral agents such as itraconazole and
fluconazole are now preferred over ketoconazole. However,
ketoconazole is inexpensive relative to the other oral agents
and it has demonstrated efficacy as a prophylactic agent
against PV [16,17].
3.2 Itraconazole
Itraconazole is a lipophilic triazole antifungal whose transmis-
sion is facilitated by sebum secretion to reach the stratum cor-
neum [18]. It works by inhibiting cytochrome P450-dependant
For personal use only.
biosynthesis of ergosterol, an essential component of the cell
wall [19]. Cauwenbergh et al. reported in 1987 that a minimum
of 1000 mg of itraconazole should be administered over 7 days
rather than 5 days to effectively treat PV [20]. Further, they
noted that clinical and mycological evidence of effective treat-
ment following itraconazole may not be apparent until 3 or
4 weeks after treatment [20]. However, in two direct clinical
comparisons of 200 mg of itraconazole administered daily
over 5 days or 7 days, it would appear that the two courses
of treatment yield comparable outcomes [21,22].
The 5 and 7-day courses of treatment have also been
compared with a single 400 mg dose of itraconazole [18,23,24]
and 400 mg daily over 3 days course of treatment [24]. Kose
et al. and Wahab et al. reported equivalent efficacy between
a daily 200 mg dose of itraconazole over 7 days and a single
400 mg dose [18,23]. In contrast, Kokturk et al. reported greater
efficacy of 400 mg of itraconazole a day over 3 days and
200 mg a day over 5 days than 400 mg in 1 day [24]. Thus,
it is unclear whether itraconazole administered in one
400 mg dose is as effective in the treatment of PV as repeated
doses over a number of days. In 2002, Faergemann et al.
conducted a study evaluating the use of itraconazole as pro-
phylaxis against relapse in patients with PV [25]. In phase 1
of the study, participants (n = 238) with mycologically
confirmed PV received 200 mg of itraconazole once daily
for 7 days. In phase 2 of the study, those that achieved myco-
logical cure (negative KOH) were randomized into one of two
arms: i) 200 mg of itraconazole twice daily, 1 day a month for
6 months; or ii) placebo twice daily, 1 day a month for
6 months. At 6 months of follow-up, a significantly greater
proportion of those in the itraconazole group maintained
Expert Opin. Pharmacother. (2014) 15(12)
Pityriasis versicolor
mycological cure than those in the placebo group (88.2 and
56.6%, p < 0.001). Fewer clinical signs and symptoms were
evident in the itraconazole group than the placebo group
(p < 0.001). Respiratory tract infection and influenza-like
symptoms were reported during phase 2 of the study. There
were no serious adverse events reported during phase 2 of
the study [25].
3.3 Fluconazole
Fluconazole is triazole antifungal that inhibits P450-
dependant biosynthesis of ergosterol [26]. Fluconazole has
also demonstrated greater efficacy in the treatment of PV
than ketoconazole [27]; it is able to reach a greater plasma con-
centration in the stratum corneum where it can persist
for ~ 2 weeks following treatment [28]. Fluconazole is effective
at multiple doses and courses of treatment, including:
i) 150 mg/week for 4 weeks; ii) 300 mg/week for 2 or 4 weeks;
iii) 300 mg every 2 weeks for 4 weeks; and iv) a single 400 mg
dose [3,29,30].
In 2010, Dehghan et al. compared oral fluconazole with
topical clotrimazole in a double-blind, randomized clinical
trial [31]. One hundred five participants with PV verified based
on clinical presentation and KOH examination were assigned
to receive a single dose of fluconazole (400 mg) and a placebo
cream (twice daily for 2 weeks) or a single dose of an oral
placebo and 1% clotrimazole cream (twice daily for 2 weeks).
Follow-up assessments evaluating clinical signs and symptoms
were performed 2, 4 and 12 weeks following treatment. Com-
plete response was defined as 95% and more lesion clearage.
At 2 weeks, there were no significant differences between the
fluconazole and clotrimazole groups on the rate of complete
(30 vs 49.1%), incomplete (66 vs 47.3%) or no clinical
responses (4 vs 3.6%) observed (c2 = 4.03, p = 0.16). At
4 weeks, a significant difference between the two groups did
emerge (c2 = 4.07, p = 0.04); however, it is unclear if the dif-
ference between the groups lay between their rate of complete
response (81.2 vs 94.9%) or incomplete response (18.8 vs
5.1%). The rates of complete (92 vs 81.8%), incomplete
(2 vs 0%) and no clinical response or recurrence (6 vs
18.2%) between the groups at week 12 were not significant
(c2 = 4.55, p = 0.77). No treatment-emergent adverse events
were reported in either group [31].
To summarize, while fluconazole is an effective treatment
against PV, it is unclear whether it performs better than
topical clotrimazole cream. It can be inferred from Dehghan’s
study that clotrimazole cream may act faster than oral flucon-
azole but, in the long term, clotrimazole cream and oral
fluconazole treat PV with similar efficacy. Additional research
is required to elucidate any true differences between oral
fluconazole and topical clotrimazole cream in the treatment
of PV.
3.4 Pramiconazole: a new oral treatment against PV
Pramiconazole is a relatively new triazole antifungal, which
targets 14-a-demethylase-dependent biosynthesis of ergosterol
1709
 A. K. Gupta & D. C. A. Lyons
[32]. In vitro, pramiconazole has demonstrated activity against
M. spp isolates similar to itraconazole and 10 times greater
than ketoconazole at concentrations < 1 µg/ml [32]. Pramicona-
zole has only been evaluated twice in clinical trials as a treatment
for PV.
In 2007, Faergemann et al. evaluated the efficacy and safety
of once-daily 200 mg pramiconazole over 3 days [33]. Nine-
teen participants with PV confirmed by KOH examination
were evaluated at baseline and days 4, 10 and 30 for clinical
and mycological signs of PV. Clinical signs and symptoms
(erythema, itching and desquamation) were rated on a
five-point scale using a global clinical evaluation (GCE).
Mycological cure was defined as a negative KOH evaluation.
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by University of Toronto on 08/11/14
At day 10, 42% of participants achieved mycological cure
and at day 30, 100% of participants achieved mycological
cure. The sum of scores from the GCE decreased significantly
from baseline (median = 8) to day 4 (median = 5), 10
(median = 3) and 30 (median = 2; p < 0.001). However,
47.4% of participants reported adverse events, including gas-
trointestinal disorders, general disorders (asthenia, feeling
hot), blood present in urine, neck pain, headache, respiratory
thoracic and mediastinal disorders, and folliculitis [33].
In 2009, Faergemann et al. undertook an extensive investi-
gation of five dosages and courses of treatment for pramicona-
For personal use only.
zole [34]. Participants (n = 147) with KOH-positive PV, mild
desquamation, multiple lesions and ‡ 15% skin involvement
were included. They were assigned to receive: i) a single dose
of 100 mg; ii) a single dose of 200 mg; iii) one 200 mg dose
daily for 2 days; iv) one 200 mg dose daily for 3 days; v) a single
400 mg dose of pramiconazole; or vi) one placebo a day for
3 days. Complete cure was defined as a negative KOH evalua-
tion and a score of 0 on an investigator global assessment (IGA)
of erythema, desquamation or pruritus. Mycological cure was
defined as a negative KOH evaluation. Upon follow-up on
day 28, a significantly greater proportion of participants
treated with a single 200 mg dose (59.1%), 200 mg/day for
2 days (72%), 200 mg/day for 3 days (84.6%) and a single
400 mg dose (52.2%) achieved complete cure than those in
the placebo group (16%) (p = 0.003, p < 0.001, p < 0.001,
p = 0.013, respectively). Similarly, a significantly greater pro-
portion of participants treated with a single 200 mg dose
(68.2%), 200 mg/day for 2 days (92%), 200 mg/day for
3 days (96.2%) and a single 400 mg dose (78.3%) achieved
mycological cure than those in the placebo group (16%)
(p < 0.001; all groups). Diarrhea and nausea were the most
frequently reported adverse events. The group treated with a
single 100 mg dose exhibited the highest proportion of adverse
events (46%) and the group receiving 200 mg/day for 3 days
the lowest (31%) [34].
Thus, pramiconazole appears to be effective at the follow-
ing doses: i) single 200 mg; ii) 200 mg/day for 2 days; iii)
200 mg/day for 3 days; and iv) single 400 mg. A number of
adverse events were reported in both studies evaluating prami-
conazole in the treatment of PV. Further research with regard
to elucidating the dose and course of treatment yielding the
1710 Expert Opin. Pharmacother. (2014) 15(12)
greatest efficacy with the lowest incidence of adverse events
are warranted. Direct comparisons of pramiconazole with
itraconazole and/or fluconazole are also warranted to establish
its efficacy and safety profile in relation to existing oral
treatments are required.
4.Systematic reviews of drug efficacy and
dosing regimens
Systematic reviews are useful tools for synthesizing available
evidence from clinical trials to get a clearer picture of a drug
efficacy. At this time, three systematic reviews have been
published. Two such reviews confirmed the efficacy of topical
treatments for PV [7,35]. One review also confirmed the
efficacy of systemic treatments as compared to placebo but,
was unable to answer whether any one dosage or course of
treatment for systemic agents was superior to another [35].
The third review sought to answer those questions [36].
Hu and Bigby synthesized data from clinical trials evaluat-
ing topical and oral treatments against PV [35]. The authors
collected, examined and compared 93 controlled trials in
children and adults with PV. The data indicated that all top-
ical azole, non-azole agents and terbinafine performed better
than placebo [35]. The performances of topical antifungals
may be enhanced given higher drug concentrations and longer
treatment durations; however, the authors reported a lack of
sufficient power to detect significant differences [35]. Mild
pruritus, burning, erythema, and skin dryness and irritation
were associated with topical antifungal agents [35].
In their evaluation of systemic treatments against PV, Hu
and Bigby reported greater efficacy of ketoconazole and
itraconazole compared to placebo [35]. Systemic antifungals
also demonstrated a tendency toward improved efficacy given
higher dosages and longer courses of treatment but, again
their analysis lacked sufficient power to detect significant dif-
ferences [35]. In addition, systemic treatments were associated
with numerous side effects, including, but not limited to,
gastrointestinal symptoms (nausea, vomiting, and diarrhea),
headache, fatigue and skin-related symptoms [35].
In Gupta et al. systematic review, they compared the
efficacy of systemic antifungals with the aim of providing dos-
age and course of treatment recommendations [36]. A total of
57 clinical trials were included in the study. Based on their
analysis, there was no association between mycological cure
rates (MCR) achieved using itraconazole and the duration of
treatment (5 or 7 days) or the daily concentrations (100,
200 or 400 mg/day) [34]. Similarly, in regard to fluconazole
there was no correlation between MCRs and the cumulative
dose, duration of treatment or weekly concentration [36].
However, multiple dosing regimens of fluconazole consis-
tently demonstrated MCRs ‡ 75%, whereas single doses
did not [36]. Ketoconazole was associated with greater MCRs
given higher cumulative doses (400 -- 5600 mg) and longer
treatment duration (1 -- 28 days) [36]. Pramiconazole was
also associated with improved MCRs given larger cumulative

Table 1. Change in dosing recommendation
2005 -- 2014.
2005 2014
recommendation recommendation
Ketoconazole* 200 mg 200 mg/day for 10 days
3 12 h apart
Itraconazole 200 mg/day 200 mg/day for 5 days
for 7 days
Fluconazole 300 mg 300 mg/wk for 2 weeks
2 2 days apart
Pramiconazole No recommendation 200 mg/day for 2 days
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by University of Toronto on 08/11/14
*Ketoconazole is no longer recommended for the treatment of superficial
fungal infection in the US, Canada and Europe.
Note: 3 = 3 times; 2 = 2 times; wk = Week.
doses (100 -- 600 mg) and longer treatment durations
(1 -- 3 days) [36].
Thus, it can be inferred from these systematic reviews
that both topical and systemic antifungals are effective treat-
ments against PV. However, there would appear to be fewer
side effects associated with topical agents than systemic agents.
Itraconazole appears to be equally effective whether adminis-
tered as a 200-mg dose over 5 or 7 days, fluconazole may
For personal use only.
provide greater efficacy when administered in multiple rather
than single doses, and ketoconazole and pramiconazole are
more effective at higher cumulative dosages and longer
treatment durations.
5. Conclusion
There are a number of effective treatments available for relief
from PV; therefore, few new pharmacological treatments
have been developed over the past decade with the exception
of 1% ketoconazole foam and oral pramiconazole. Ketocona-
zole foam, a topical agent with enhanced penetration,
demonstrated comparable efficacy and safety to 2% topical
ketoconazole cream in the treatment of PV [8]. Similarly, oral
pramiconazole, a new oral triazole antifungal, demonstrated
efficacy at multiple doses (a single 200 mg dose, 200 mg/day
for 2 days, 200 mg/day for 3 days and a single 400 mg dose)
as a treatment against PV [33,34]. However, pramiconazole
was associated with a number of adverse side effects. Thus,
1% ketoconazole foam and pramiconazole may represent two
new alternative pharmacological treatment options for PV.
Systematic reviews have attempted to amalgamate and
compare existing clinical trials. While these reviews were able
to confirm the efficacy of topical or oral agents as compared
to placebo, they are unable to perform indirect statistical com-
parisons between existing topical and oral antifungal agents.
Nonetheless, one review was able to elucidate evidence-based
dosing recommendations for oral antifungals were once there
were none [36]. Establishing evidence-based dosing regimens
for oral treatments is of utmost importance for optimizing
efficacy while minimizing side effects.
Expert Opin. Pharmacother. (2014) 15(12)
Pityriasis versicolor
6. Expert opinion
It is unclear what causes the conversion of M. spp yeast to its
mycelial form but, oily skin is a known risk factor [1,4]. Indeed,
PV primarily affects post-pubescent adolescents and adults,
occurs more often in tropical climates, and PV lesions tend to
coincide with bodily regions rife with sebaceous glands [6].
The persistent presence of M. spp on the skin results in a high
lifetime risk of recurrence following successful treatment [3,6].
Topical antifungals are effective and inexpensive treatments
against PV. However, topical agents are only effective when
applied properly and patient compliance may be subopti-
mal [3]. Systemic antifungals may be warranted where topical
agents are ineffective or in severe cases where lesions have coa-
lesced across a significant portion of the body. To date, there
are no standard dosing regimens available for administration
of systemic antifungals in the treatment of PV [36].
Oral ketoconazole is an older systemic antifungal. It is no
longer approved for superficial fungal infections in the United
States, Canada or Europe due to its hepatotoxic side effects
[12-15]. Thus, the authors only recommend ketoconazole where
topical agents and newer antifungals are ineffective. In such
cases, we recommend 200 mg/day for 10 days. This recom-
mendation is in contrast to our 2005 recommendation
(Table 1) [3]; however, there is evidence to suggest that ketoco-
nazole is more effective at higher cumulative dosages and
longer treatment durations [36].
Itraconazole is a well-established treatment against PV.
Some debate regarding whether itraconazole ought to be
administered over 5 or 7 days has persisted for many years.
Recent evidence suggests that itraconazole is equally effective
when administered at 200 mg/day for 5 or 7 days [36]. Thus,
in contrast to our previous recommendation of 7 days [3],
the authors recommend 200 mg once daily for 5 days rather
than 7, thereby facilitating patient compliance (Table 1).
Fluconazole is also an effective treatment against PV. It
appears most effective at 150 and 300 mg/week dosages
whether administered over 2 or 4 weeks [35,36]. Fluconazole
administered in multiple 300 mg doses appears to achieve
greater MCRs than multiple 150 mg doses [36]. As such, the
authors recommend 300 mg of fluconazole per week for
2 weeks (Table 1).
Pramiconazole is an emerging antifungal treatment for PV.
Pramiconazole appears to be most effective when administered
as 200 mg/day for 2 or 3 days [34]. This inference may be further
supported by recent evidence suggesting improved MCRs given
larger cumulative doses and longer treatment duration [36].
Thus, the authors recommend 200 mg once daily for 2 days
of pramiconazole (Table 1). Nevertheless, further research
evaluating pramiconazole at various concentrations, dosing
regimens, and in comparison to existing systemic agents are
necessary.
Posaconazole and voriconazole, two alternative azoles, may
hold promise as systemic treatments against PV. In vitro,
1711
 A. K. Gupta & D. C. A. Lyons

posaconazole and voriconazole have demonstrated similar
minimal inhibitory concentrations against M. spp isolates as
ketoconazole, itraconazole and fluconazole [37-39]. However,
in vitro data often do not translate well into clinical efficacy.
Therefore, clinical trials evaluating these two potential treat-
ments are warranted in order to establish their efficacy in
treating human PV.
Recently published systematic reviews indicate a lack of
direct comparisons between topical and systemic agents in
the literature and substandard reporting habits associated
with published clinical trials. In the future, topical and
systemic agents ought to be evaluated in combination with
one another and compared against one another. Furthermore,
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by University of Toronto on 08/11/14
conducting clinical trials is recommended in the future to
facilitate the synthesis of clinical trials for evaluation in
meta-analyses.
Declaration of interest
AK Gupta and DCA Lyons are associated with Mediprobe
Research, a private company, which did not receive any finan-
cial contributions from any sponsor and no sponsor was
involved in the writing of this manuscript. The authors have
no other relevant affiliations or financial involvement with
any organization or entity with a financial interest in or finan-
cial conflict with the subject matter or materials discussed in

heedful regard for proper reporting techniques when the manuscript apart from those disclosed.

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Affiliation
Aditya K Gupta†1,2 MD PhD FAAD FRCP(C)
& Danika CA Lyons2 MSc
†
Author for correspondence
1
University of Toronto, Department of Medicine,
Toronto, Canada
2
Mediprobe Research, Inc., 645 Windermere
Road, London, Ontario, N5X 2P1, Canada
Tel: +1 519 851 9715;
Fax: +1 519 657 4233;
E-mail: agupta@execulink.com
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