Current Fungal Infection Reports

https://doi.org/10.1007/s12281-018-0328-7

FUNGAL INFECTIONS OF SKIN AND SUBCUTANEOUS TISSUE (A BONIFAZ, SECTION

EDITOR)

Pityriasis Versicolor: Treatment Update

Martin Arce 1 & Daniela Gutiérrez-Mendoza 1

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review To address the latest treatments used for pityriasis versicolor and identify those that have proven to be
effective in recent publications.
Recent Findings Even though Malassezia spp. have shown resistance to antifungals, classical treatments continue to be effective,
and other novelty therapies including light therapies have shown promising results in the treatment of this condition.
Summary Pityriasis versicolor is a common superficial fungal infection of the skin. There are numerous and diverse topical and
systemic therapeutic options that are successful for the treatment and prophylaxis of this mycosis. New substances that act against
the fungus through other mechanisms of action different from those used until now are expected in the near future.

Keywords Superficial mycosis . Tropical mycosis . Pytiriasis versicolor . Tinea versicolor . Malassezia spp. . Antifungals

Introduction
Pityriasis versicolor, or tinea versicolor, is a mildly inflamma-
torily superficial mycosis with a chronic and relapsing course.
It is easy to recognize by its characteristic light or dark colored
oval or circular patches with fine and superficial desquama-
tion, and a tendency to form groups of larger patches. The
disease affects the oily or seborrheic areas of the body such
as the trunk, posterior and anterior thorax, neck, arms, and
face: especially in the forehead and around the ears. It can also
be seen in the large skin folds, specially at hyperhidrosis sites
[1–3].
There are clinical varieties of the disease: (1) According to
the predominance of the color of the spots, the most frequent
are the hyperpigmented variety with brown spots and the
hypopigmented variety with white spots, also referred to as
the alba form, followed by the erythematous variety with red-
dish spots (Fig. 1a) [1, 4, 5]. (2) In relation to the morphology
This article is part of the Topical Collection on Fungal Infections of Skin
and Subcutaneous Tissue
* Martin Arce
1
Tijuana, Mexico
of the lesion, there are papular and imbricate forms, and there
is an atrophic type rarely reported in the literature [3, 6].
Recently, a new disseminated and recurrent variety of
pytiriasis versicolor has been suggested based on the clinical
characteristics of extension and evolution [7].
Pityriasis versicolor can be found mainly in young patients,
as well as children and adults, more commonly in the summer
or in hot climate and high humidity environments; other
influencing factors include sun exposure, excessive sweating,
application of creams or oils on the skin and hair, and use of
tight clothing or synthetic fabrics [3, 4, 8]. In tropical coun-
tries, the disease has been found in 32% of the mycoses stud-
ied and can be the cause in up to 40 to 50% of individuals. It
has also been found to have a high recurrence rate, with 60%
relapse after treatment before 1 year and 80% in a period of
2 years [8–10].
The disease can be managed by various therapeutic modal-
ities. In general, the choice depends on the clinical variety and
the causal agent; however, the age of the individual, the sever-
ity or extension of the lesions, the recurrence of the disease,
and other medications prescribed to the patient may influence
the type of treatment [4, 8, 11•]. When adequate treatment is
employed, resistant cases are extraordinary, but if it is the case,
it may be due to inappropriate treatment or incorrect diagno-
sis. Residual spots may be observed after treatment because
pigmentation is slow to recover [12, 5].

Fig. 1 a Hypopigmented circular
spots and confluent, with smooth
scale. b Skin scales on transparent
adhesive tape on slides. c
Microscopic exam: yeasts and
filaments stained with
lactophenol blue
Aetiological Agent
Malassezia genus is the predominant commensal of the skin
microbiota of healthy adults in the back and specific areas of
the head and face, occiput, external auditory canal, glabella,
and atrial fold, as well as sternal manubrium and inguinal
crease; however, it can be found as a yeast and symbiont in
practically all the cutaneous surface [13, 14]. The former rep-
resent seborrheic areas; these anatomic sites are preferred by
Malassezia spp. because it utilizes the fatty acids as exoge-
nous sources of lipids for nutritional requirements. Enzymes
such as lipases and phospholipases are necessary to assimilate
the lipids of the host’s sebum [2, 15].
The genus Malassezia has been reclassified within the
class Malasseziomycetes, in Ustilaginomyco tina
(Basidiomycota, fungi) and new species have been identi-
fied. Almost all of them are obligatory lipophilic yeasts. At
this moment, 17 species of the genus are recognized
[15–17, 18••, 19••]. Malassezia globosa, M. simpodialis,
and M. furfur are most frequently isolated in Pityriasis
versicolor [2, 20–23]. M. pachydermatis, the only species
not dependent on lipids, has rarely been reported as caus-
ative of the disease [15, 24].
Diagnosis
The diagnosis of pityriasis versicolor is done by clinical
observation of the characteristic lesions; a green-yellow
fluorescence in the depigmented macules on Wood’s light
examination can help corroborate the diagnosis.
Laboratory analysis of the scales under the light micro-
scope will show the dimorphism of the fungus with short
and thick filaments and yeast cells. A smear is easily ob-
tained from the surface of the skin by scraping scales with
adhesive tape and stained with Alibert’ solution or
Lactophenol cotton blue and methylene blue, or with
Curr Fungal Infect Rep
10%–20% potassium hydroxide (KOH) (Fig. 1b, c) [8].
The isolation of the yeasts that require lipids can be done
in enriched media such as Dixon Agar (DA), modified
Dixon (mDA), Leeming and Notman Agar (LNA), or
Sabouraud Agar with olive oil. Analytical and molecular
methods like real-time PCR that do not require culture can
also be employed. The histopathological study may be per-
formed for academic or research reasons, but it is not re-
quired for the diagnosis of the disease [21–23, 25].
Treatment
Non-specific Topical Treatments
Topical treatments with keratolytic and antimicrobial ac-
tivity, without specific antifungal activity against
Malassezia spp., have been used for a long time. They
have proved to be an effective treatment for pityriasis
versicolor and continue to be considered as first line of
treatment. These therapies include made to order formula-
tions and over the counter medications that encompass
various presentations such as tinctures, ointments, creams
or lotions, soaps, and shampoos. The main substances
used are sulfur, salicylic acid, benzoic acid, propylene gly-
col, and benzoyl peroxide, at different concentrations, ei-
ther alone or combined with other products [4, 26]. This
group includes retinoid drugs such as tretinoin (retinoic
acid) and adapalene 0.1%. They act as keratolytics in pit-
yriasis versicolor by increasing the exfoliation of the stra-
tum corneum, where the fungus is found [27]. Physical
treatments with mechanical keratolytic effects such as ex-
foliation of the skin with loofah during the bath are also
mentioned as effective [28]. Miscellaneous topical drugs
such as diclofenac 1%, a non-steroidal anti-inflammatory
drug, have been tested in pityriasis versicolor [29].
Curr Fungal Infect Rep
Specific Topical Treatments
Antifungal drugs have traditionally been used in pityriasis
versicolor. These include haloprogin, thiocarbamates such as
tolnaftate and tolciclate, as well as cyclopirox olamine 1%,
zinc pyrithione 1%, and various imidazoles 1–2%, for exam-
ple, clotrimazole and miconazole, and recently the triazole
fluconazole 2% in shampoo [8, 30, 31]. In the last years, the
antifungal mechanism of zinc pyrithione has been described.
It acts as an ionophore, apparently increasing cellular copper
levels and inhibiting the growth of the fungus [32, 33].
Currently, topical medications such as ketoconazole and
terbinafine are considered first-line treatments that can be ap-
plied directly on the skin in cream, gel, foam, or shampoo
formulations. Ketoconazole 2%, cream or foam, including
shampoo, is used one to two times a day for 14 days, while
terbinafine 1% cream, emulsion or solution, twice a day, 1 or
2 weeks [11•, 28, 31, 34•].
Topical treatments are effective, accessible, and less expen-
sive. They have some disadvantages compared to oral treat-
ments. They may be relatively difficult to self-apply and in
some cases cause skin irritation. In cases of pityriasis
versicolor with extensive lesions, frequent relapses, resistant
lesions, or lack of adherence to topical treatment, systemic
therapy is recommended. It has the disadvantage of probable
adverse effects or interactions with other drugs [35, 36, 8, 31,
11•].
Systemic Treatment
Ketoconazole, itraconazole, and fluconazole are well known
oral azole broad-spectrum antifungals for superficial and deep
mycoses. Ketoconazole is one of the main oral imidazole
medications used in pityriasis versicolor; its effectiveness in
the treatment and prophylaxis of the disease has solid evi-
dence during decades of clinical use. The posology of ketoco-
nazole for the treatment of the disease is 200 mg per day
during 10 days and for prophylaxis 200 mg day during 3 days.
Ketoconazole has excellent activity against M. furfur at con-
centrations of 0.8 μg/mL, but at concentrations higher than
100 μg/mL, it has toxic effects. Adverse effects are mostly
mild and affect the gastrointestinal tract, while serious adverse
effects are rare and include hypersensitivity reactions, anaphy-
laxis and liver toxicity, the latter previously estimated at
1:500,000 patients taking 10 days of oral treatment. In recent
years, the risk of hepatotoxicity by oral ketoconazole in 1:500
has been calculated and this use has been banned, specifically
in Europe and the USA, but its use continues in other regions
[37, 28, 31, 11•].
Itraconazole, fluconazole, and the newer pramiconazole are
triazole compounds, with high cure rates in pityriasis
versicolor. They are administered orally since there are no
formulations for topical use, except for fluconazole shampoo.
The first, itraconazole, is highly lipophilic with affinity to
keratinized tissue. Pramiconazole is also broad-spectrum an-
tifungal and more effective than ketoconazole against derma-
tophytes and yeasts such as Candida spp. and Malassezia spp.
The three agents are well tolerated, with mild side effects such
as headache, and most commonly gastrointestinal complaints;
these adverse effects are the same as in those observed with
ketoconazole, but without its hepatotoxicity and more impor-
tantly they are most active against Malassezia spp. [37, 38•].
The recommended dosage is as follows: itraconazole
200 mg per day for 5 to 7 days, fluconazole 300 mg weekly
for 2 weeks, or a single dose of 450 mg, and pramiconazole
200 mg daily for 2 days. Oral terbinafine is not useful in
pityriasis versicolor [31, 34•, 11•].
Mechanism of Fungal Resistance to Azoles
Azole antifungals act directly on the cell membrane of the
fungus, affecting its integrity and growth, by inhibiting the
cytochrome p450 14α-lanosterol demethylase enzymatic
function. Mechanisms of azole resistance have been de-
scribed, such as increased drug efflux, target mutations such
as decreased affinity, dysregulation of target expression, and
alterations in ergosterol biosynthesis [39, 40, 41]. It has been
observed that species such as M. pachydermatis and M. furfur
can depend on cellular efflux pumps to resist the action of
azoles [42••].
Antifungal Susceptibility
The antifungal susceptibility for Malassezia spp. has been
demonstrated in vitro against azoles such as itraconazole,
voriconazole, ketoconazole, and fluconazole [43–45]. To de-
termine this antifungal susceptibility in vitro of Malassezia
spp., methods adapted to the strict growth requirements of
these yeasts are needed. They are made in culture media such
as agar and broth. Currently, there are few tests implemented
and are not practiced routinely since they are complex and are
only done in highly specialized laboratories [45–47].
Diverse Compounds in the Treatment Infections
by Malassezia spp.
Phytotherapy has been reported in the treatment of pityriasis
versicolor with numerous medicinal plants, which contain var-
ious compounds such as phenols, flavonoids, tannins, antho-
cyanins, as substances with antifungal properties against
Malassezia spp. [48, 49]. Recently, alternative and novel treat-
ments different from classical azole antifungals in Malassezia
spp. have been reviewed, and some of them could be useful in
pityriasis versicolor; inhibitors and activators of carbonic
anhydrase of M. globosa, inhibitors of lipase of M. globosa,
silver nanoparticles combined with other antifungals, and

inhibitors of calcineurin phosphatase, pimecrolimus, and ta-
crolimus, which also prohibits the growth of Malassezia spp.
[38•, 34, 33]. The mechanism of action of tacrolimus has been
investigated in M. furfur and M. sympodialis; this drug binds
to an immunophilin (FKBP12), and inhibits fungal calcine-
urin, which is involved in fungal growth and susceptibility-
resistance to antifungal drugs [50]. In one study of clinical
efficacy, tacrolimus was similar to clotrimazole [51].
Phototherapy and Other Light Treatments
Nowadays, the use of technology with different sources of
light energy in superficial fungal infections such as pityriasis
versicolor is increasingly frequent [52–54]. Photodynamic
therapy with methyl 5 aminolevulinate has been used against
infection by Malassezia spp. [55–57]. Recently, narrow-band
ultra violet B (NB-UVB) light has been used as a safe and
effective alternative treatment in pityriasis versicolor, al-
though it does not prevent relapses [58]. UV light has also
been used to accelerate the recovery of discoloration once
the fungus has been eliminated; although the repigmentation
of residual hypopigmented spots of pityriasis versicolor re-
solves naturally in 2 to 3 months or longer after the end of
treatment, it is recommended to begin therapy as soon as pos-
sible [5].
Prophilaxis and Prevention
In recurrent cases, drug prophylaxis is suggested at the start of
summer or in warm, humid and sunny environments, in addi-
tion to modification of predisposing factors. Ketoconazole 2%
shampoo 1 to 3 days and selenium disulfide shampoo once
every 3 months. Oral maintenance therapy with Itraconazole
200 mg, twice a day, every month and fluconazole 300 mg
every month [28, 11•, 34•].
Patients exposed to environments with humidity and heat
can be educated in preventive measures aimed at lowering
recurrence rates: Bathing twice a day or after intense sweating,
avoiding the use of oil based products for skin and hair care,
using loose clothing with natural fibers that are fresh and
absorbent, avoiding tight and synthetic clothing, and avoiding
direct exposure to the sun and artificial tanning. It is important
to disclose information and preventive measures about the
disease that are free and easy to understand to the general
public, in the form of posters, brochures or electronic media,
especially in countries where the condition prevails [10, 59].
Conclusion
Yeasts of the genus Malassezia spp. are part of the biota of
mammals and birds. They inhabit the human skin in a ubiqui-
tous way so it is impossible to eradicate them from this natural
Curr Fungal Infect Rep
ecological niche; under certain exogenous and endogenous
conditions, they produce pityriasis versicolor. This condition
has a benign nature but nevertheless requires treatment be-
cause it negatively affects the quality of life of the subjects
who suffer from it.
The drugs currently available for the treatment of pityriasis
versicolor are effective and safe. Topical and systemic azole
medications continue to be the main basis of their treatment,
among multiple options and promising compounds. The
choice of treatment depends basically on the extent or severity
of the lesions and recurrence of the disease, as well as the
availability and cost of the therapy and the physician’s
experience.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interests.
Human and Animal Rights and Informed Consent There was no exper-
iment done on human or animal subjects by any of the authors for the
publication of this article.
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1. Gaitanis G, Velegraki A, Mayser P, Bassukas ID. Skin diseases
associated with Malassezia yeasts: facts and controversies. Clin
Dermatol. 2013;31:455–63.
2. Harada K, Saito M, Sugita T, Tsuboi R. Malassezia species and
their associated skin diseases. J Dermatol. 2015;42:250–7. https://
doi.org/10.1111/1346-8138.12700.
3. Rios-Yuil JM. Pityriasis versicolor: clinical spectrum and diagnosis.
Curr Fungal Infect Rep. 2016;10:121–5. https://doi.org/10.1007/
s12281-016-0261-6.
4. Borelli D, Jacobs PH, NaIl L. Tinea versicolor: epidemiologic, clin-
ical, and therapeutic aspects. J Am Acad Dermatol. 1991;25:300–5.
5. Thoma W, Krämer HJ, Mayser P. Pityriasis versicolor alba. J Eur
Acad Dermatol Venereol. 2005;19(2):147–52. https://doi.org/10.
1111/j.1468-3083.2004.01085.x.
6. Cullingham K, Hull PR. Atrophying pityriasis versicolor. CMAJ.
2014;186(10):776. https://doi.org/10.1503/cmaj.131846.
7. Romero-Sandoval K, Costa AA, Teixeira Sousa MG, et al.
Recurrent and disseminated pityriasis versicolor: a novel clinical
form consequent to Malassezia-host interaction? Med Hypotheses.
2017;109:139–44. https://doi.org/10.1016/j.mehy.2017.10.013.
8. Faergemann J. Management of seborrheic dermatitis and pityriasis
versicolor. Am J Clin Dermatol. 2000;1:75–80. https://doi.org/10.
2165/00128071-200,001,020-00001.
9. Isa-Isa R, Cruz AC, Arenas R, Duarte Y, Linares L, Bogaert H.
Pitiriasis versicolor en niños. Estudio epidemiológico y
micológico de 797 casos estudiados en la República Dominicana.
Med Cutan Iber Lat Am. 2002;30(1):5–8.
Curr Fungal Infect Rep
10. Motta de Morais P, Souza Cunha MG, Moreira Frota MZ. Clinical
aspects of patients with pityriasis versicolor seen at a referral center
for tropical dermatology in Manaus, Amazonas, Brazil. An Bras
Dermatol. 2010;85(6):797–803.
11.• Gupta A, Foley K. Antifungal treatment for pityriasis versicolor. J
Fungi. 2015;1:13–29. https://doi.org/10.3390/jof1010013 A
review and evaluation of studies conducted with azole
antifungics and terbinafine in pityriasis versicolor is presented.
12. Helou J, Obeid G, Moutran R, Maatouk I. Pityriasis versicolor: a
case of resistance to treatment. Int J Dermatol. 2014;53(2):e114–6.
https://doi.org/10.1111/j.13654632.2012.05689.x.
13. Findley K, Oh J, Yang J, et al. Topographic diversity of fungal and
bacterial communities in human skin. Nature. 2013;000:1–4.
https://doi.org/10.1038/nature12171.
14. Jo J-H, Kennedy EA, Kong HH. Topographical and physiological
differences of the skin mycobiome in health and disease. Virulence.
2017;8:324–33. https://doi.org/10.1080/21505594.2016.1249093.
15. Sparber F, LeibundGut-Landmann S. Host responses to Malassezia
spp in the mammalian skin. Front Immunol. 2017;8:1614. https://
doi.org/10.3389/fimmu.2017.01614.
16. Wang QM, Theelen BT, Groenewald M, Bai FY, Boekhout T.
Moniliellomycetes and Malasseziomycetes, two new classes in
Ustilaginomycotina. Persoonia. 2014;33:41–7. https://doi.org/10.
3767/003158514X682313.
17. Wu G, Zhao H, Li C, et al. Genus-wide comparative genomics of
Malassezia delineates its phylogeny, physiology, and niche adapta-
tion on human skin. PLoS Genet. 2015;11(11):e1005614. https://
doi.org/10.1371/journal.pgen.1005614.
18.•• Honnavar P, Prasad GS, Ghosh A, et al. Malassezia arunalokei sp.
nov., a novel yeast species isolated from seborrhoeic dermatitis
patients and healthy individuals from India. J Clin Microbiol.
2016. https://doi.org/10.1128/JCM.00683-16 This article
introduces a new species of Malassezia found in human skin.
19.•• Cabañes FJ, Coutinho DA, Puig L, Bragulat R, Castella G. New
lipid-dependent Malassezia species from parrots. Nuevas especies
lipodependientes del género Malassezia procedentes de loros. Rev
Iberoam Micol. 2016;33:92–9. https://doi.org/10.1016/j.riam.2016.
03.003 This publication presents another novo species of
Malassezia isolated in birds.
20. Crespo Erchiga V, Ojeda Martos A, Vera Casaño A, Crespo Erchiga
A, Sanchez FF. Malassezia globosa as the causative agent of pity-
riasis versicolor. Br J Dermatol. 2000;143(4):799–803.
21. Morishita N, Sei Y, Sugita T. Molecular analysis of Malassezia mi-
croflora from patients with pityriasis versicolor. Mycopathologia.
2006;161:61–5. https://doi.org/10.1007/s11046-005-0149-4.
22. Prohic A, Jovovic Sadikovic T, Krupalija-Fazlic M, Kuskunovic-
Vlahovljak S. Malassezia species in healthy skin and in dermato-
logical conditions. Int J Dermatol. 2016;55:494–504.
23. White TC, Findley K, Dawson TL Jr, et al. Fungi on the skin:
dermatophytes and Malassezia. Cold Spring Harb Perspect Med.
2014;4:a019802.
24. Cruz R, Vieille P, Giusiano G, Sosa MA. Pitiriasis versicolor por
Malassezia pachydermatis: Caso clínico. Pityriasis versicolor
caused by Malassezia pachydermatis: Clinical case. Bol Micol.
2010;25:37–4. https://doi.org/10.22370/bolmicol.2010.25.0.72.
25. Velegraki A, Cafarchia C, Gaitanis G, Iatta R, Boekhout T.
Malassezia infections in humans and animals: pathophysiology,
detection, and treatment. PLoS Pathog. 2015;11(1):e1004523.
https://doi.org/10.1371/journal.ppat.1004523.
26. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for
superficial mycotic infections of the skin: pityriasis (tinea)
versicolor. J Am Acad Dermatol. 1996;34:287–9.
27. Shi TW, Zhang JA, Tang YB, et al. A randomized controlled trial of
combination treatment with ketoconazole 2% cream and adapalene
0.1% gel in pityriasis versicolor. J Dermatol Treat. 2014:1–4.
https://doi.org/10.3109/09546634.2014.921661.
28. Dias MFRG, Quaresma-Santos MVP, Bernardes-Filho F, et al.
Update on therapy for superficial mycoses: review article part I.
An Bras Dermatol. 2013;88(5):764–74. https://doi.org/10.1590/
abd1806-4841.20131996.
29. Sharquie KE, Al-Hamamy HM, Noaimi AA, Al-Shawi IA.
Treatment of pityriasis versicolor using 1% diclofenac gel and clo-
trimazole cream (comparative therapeutic study). JSSDDS.
2011;15:19–23. https://doi.org/10.1016/j.jssdds.2010.10.004.
30. Fernández-Vozmediano JM, Armario-Hita JC. Etiopatogenia y
tratamiento de la pitiriasis versicolor. Med Clin (Barc). 2006;126:
7–13.
31. Bamford JTM, Flores-Genuino RNS, Ray S, et al. Interventions for
the treatment of pityriasis versicolor. Cochrane Database Syst Rev
2014; Issue 7. Art. No.: CD011208. https://doi.org/10.1002/
14651858.CD011208.
32. Reeder NL, Kaplan J, Xu J, et al. Zinc pyrithione inhibits yeast
growth through copper influx and inactivation of iron-sulfur pro-
teins. Antimicrob Agents Chemother. 2011;55:5753–60. https://
doi.org/10.1128/AAC.00724-11.
33. Saunders CW, Scheynius A, Heitman J. Malassezia fungi are spe-
cialized to live on skin and associated with dandruff, eczema, and
other skin diseases. PLoS Pathog. 2012;8(6):e1002701. https://doi.
org/10.1371/journal.ppat.1002701.
34.• Hald M, Arendrup MC, Svejgaard EL, et al. Evidence-based
Danish guidelines for the treatment of Malassezia – related skin
diseases. Acta Derm Venereol. 2015;95:12–9 Analysis and treat-
ment recommendations for Malassezia infections based on evi-
dence level.
35. Pérez AR. Resultados del tratamiento con yodo salicílico y
ketoconazol en la pitiriasis versicolor. Rev. haban cienc méd
[Internet]. 2008;7:1–10 http://scielo.sld.cu/scielo.php?script=sci_
arttext&pid=S1729-519X2008000100019&lng=es.
36. Rivard SC. Pityriasis versicolor: avoiding pitfalls in disease diag-
nosis and therapy. Mil Med. 2013;178(8):904–6. https://doi.org/10.
7205/MILMED-D-13-00057.
37. Heeres J, Meerpoel L, Lewi P. Conazoles. Molecules. 2010;15:
4129–88. https://doi.org/10.3390/molecules15064129.
38.• Angiolella L, Carradori S, Maccallini C, Giusiano G, Supuran CT.
Targeting Malassezia species for novel synthetic and natural anti-
dandruff agents. Curr Med Chem. 2017;24:1–21. https://doi.org/10.
2174/0929867324666170404110631 Article review of new
treatments focused on Malassezia infections.
39. Vandeputte P, Ferrari S, Coste AT. Antifungal resistance and new
strategies to control fungal infections. Int J Microbiol.
2012;2012(713687):26. https://doi.org/10.1155/2012/713687.
40. Scorzoni L, de Paula e Silva ACA, Marcos CM, et al. Antifungal
therapy: new advances in the understanding and treatment of my-
cosis. Front Microbiol. 2017;8:36. https://doi.org/10.3389/fmicb.
2017.00036.
41. Fuentefria AM, Pippi B, Dalla Lana DF, Donato KK, de Andrade
SF. Antifungals discovery: an insight into new strategies to combat
antifungal resistance. Lett Appl Microbiol. 2018;66(1):2–13.
https://doi.org/10.1111/lam.12820.
42.•• Iatta R, Puttilli MR, Immediato D, et al. The role of drug efflux
pumps in Malassezia pachydermatis and Malassezia furfur defense
against azoles. Mycoses 2016; 1–5. https://doi.org/10.1111/myc.
12577. This publication explains one of the resistance
mechanisms Malassezia spp. anti-fungal against.
43. Gupta AK, Kohli Y, Li A, Faergemann J, Summerbell RC. In vitro
susceptibility of the seven Malassezia species to ketoconazole,
voriconazole, itraconazole and terbinafine. Br J Dermatol.
2000;142:758–65.
44. Cafarchia C, Iatta R, Immediato D, Puttilli R, Otranto D. Azole
susceptibility of Malassezia pachydermatis and Malassezia furfur
and tentative epidemiological cut-off values. Med Mycol. 2015;00:
1–6. https://doi.org/10.1093/mmy/myv049.

45. Miranda KC, de Araujo CR, Costa CR, et al. Antifungal activities
of azole agents against the Malassezia species. Int J Antimicrob
Agents. 2007;29(3):281–94. https://doi.org/10.1016/j.ijantimicag.
2006.09.016.
46. Rojas FD, Córdoba SB, Sosa MA, et al. Antifungal susceptibility
testing of Malassezia yeast: comparison of two different methodol-
ogies. Mycoses. 2016:1–8. https://doi.org/10.1111/myc.12556.
47. Leong C, Buttafuoco A, Glatz M, Bosshard PP. Antifungal suscep-
tibility testing of Malassezia spp. with an optimized colorimetric
broth microdilution method. J Clin Microbiol. 2017;55:1883–93.
https://doi.org/10.1128/JCM.00338-17.
48. Sepahvand A, Eliasy H, Rahimi H, et al. Phytotherapy for tinea
versicolor. Int J Health Med Curr Res. 2017;2:592–9. https://doi.
org/10.22301/IJHMCR.2528-3189.592.
49. Rhimi W, Salem IB, et al. Chemical composition, antibacterial and
antifungal activities of crude Dittrichia viscosa (L.) greuter leaf
extracts. Molecules. 2017;22(942):1–13. https://doi.org/10.3390/
molecules22070942.
50.• Ianiri G, Applen Clancey S, Lee SC, Heitman J. FKBP12-
dependent inhibition of calcineurin mediates immunosuppressive
antifungal drug action in Malassezia. mBio. 8:e01752–17. https://
doi.org/10.1128/mBio.01752-17 This study paves the use of
calcineurin inhibitors as alternatives in the treatment of
pityriasis versicolor.
51. Sepaskhah M, Sadat MS, Pakshir K, Bagheri Z. Comparative effi-
cacy of topical application of tacrolimus and clotrimazole in the
treatment of pityriasis versicolor: a single blind, randomized clinical
trial. Mycoses. 2017;60(5):338–42. https://doi.org/10.1111/myc.
12598.
Curr Fungal Infect Rep
52. Qiao J, Li R, Ding Y, Fang H. Photodynamic therapy in the treat-
ment of superficial mycoses: an evidence-based evaluation.
Mycopathologia. 2010;170(5):339–43. https://doi.org/10.1007/
s11046-010-9325-2.
53. Dai T, Fuchs BB, Coleman JJ, et al. Concepts and principles of
photodynamic therapy as an alternative antifungal discovery plat-
form. Front Microbiol. 2012;3:1–16. https://doi.org/10.3389/fmicb.
2012.00120.
54. Penjweini R, Mokmeli S, Becker K, Dodt HU, Saghafi S. Effects of
UV-, visible-, near-infrared beams in three therapy resistance case
studies of fungal skin infections. OPJ. 2013;3:1–10. https://doi.org/
10.4236/opj.2013.37A001.
55. Kim YJ, Kim YC. Successful treatment of pityriasis versicolor with
5-aminolevulinic acid photodynamic therapy. Arch Dermatol.
2007;143:1218–9. https://doi.org/10.1001/archderm.143.9.1218.
56. Abreu L, Adriano AR, Félix Bravo B, et al. Treatment of pityriasis
versicolor with photodynamic therapy. J Am Acad Dermatol 2013;
68(4):S1, AB131. https://doi.org/10.1016/j.jaad.2012.12.542
57. Gilaberte Y, Aspiroz C, Alejandre C, Rezusta A. Crecimiento de
Malassezia en piel peritumoral tras terapia fotodinámica con metil-
5-aminolevulinato para queratosis actínica y cáncer de piel no mel-
anoma. Actas Dermosifiliogr. 2015;106:70–1.
58. Balevi A, Üstüner P, Kakşi SA, Özdemir M. Narrow-band UV-B
phototherapy: an effective and reliable treatment alternative for ex-
tensive and recurrent pityriasis versicolor. J Dermatol Treat. 2017;9:
1. https://doi.org/10.1080/09546634.2017.1364690.
59. Ibekwea PU, Ogunbiyib AO, Ruzickac T, Sa‘rdyc M. Quality of
life determinants in secondary school students with pityriasis
versicolor. J Egypt Women Dermatol Soc. 2015;12:49–54. https://
doi.org/10.1097/01.EWX.0000452297.12250.87.