Tinea Versicolor (Pityriasis Versicolor)

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Tinea versicolor (pityriasis versicolor)

AUTHORS: Beth G Goldstein, MD, Adam O Goldstein, MD, MPH
SECTION EDITORS: Robert P Dellavalle, MD, PhD, MSPH, Moise L Levy, MD, Ted Rosen, MD
DEPUTY EDITOR: Abena O Ofori, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2023.

This topic last updated: Nov 01, 2022.
INTRODUCTION
Tinea versicolor (ie, pityriasis versicolor) is a common superficial fungal infection. Patients
with this disorder often present with hypopigmented, hyperpigmented, or erythematous
macules on the trunk and proximal upper extremities ( picture 1A-E). Unlike other disorders
utilizing the term tinea (eg, tinea pedis, tinea capitis), tinea versicolor is not a dermatophyte
infection. The causative organisms are saprophytic, lipid-dependent yeasts in the genus
Malassezia (formerly known as Pityrosporum) [1].
Tinea versicolor responds well to medical therapy ( table 1), but recurrence is common and
long-term prophylactic therapy may be necessary. The clinical features, diagnosis, and
management of tinea versicolor will be reviewed here.
EPIDEMIOLOGY
Tinea versicolor occurs worldwide, but the highest incidence is found in tropical climates.
Prevalence of up to 50 percent has been reported in some tropical countries [2]. In
Scandinavia, the prevalence has been estimated to be approximately 1 percent [2].
Tinea versicolor most commonly affects adolescents and young adults, but can also occur in
children and has been reported in infants [3-6]. The disorder is not contagious, although
successful inoculation has occurred under experimental conditions utilizing topical oils and
occlusion [7,8].
PATHOGENESIS AND RISK FACTORS

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Malassezia is a lipid-dependent, dimorphic fungus that is a component of normal skin flora.

Transformation of Malassezia from yeast cells to a pathogenic mycelial form is associated with
the development of clinical disease. External factors suspected of contributing to this
conversion include exposure to hot and humid weather, hyperhidrosis, and the use of topical
skin oils [9]. Tinea versicolor is not related to poor hygiene.
Host characteristics that contribute to the development of tinea versicolor are poorly
understood. A genetic predisposition may be involved [10]. In a questionnaire-based study,
21 percent of patients reported a positive family history of the disease [11]. Tinea versicolor
also occurs more commonly in patients who are immunosuppressed, suggesting that an
altered host immune response may play a role in the pathogenesis [12]. Oral contraceptive
therapy and malnutrition may be additional predisposing factors [13].
M. globosa appears to be the predominant causal species in tinea versicolor [14-16]. M.

sympodialis, M. furfur, and other Malassezia species have also been implicated [17]. (See
"Invasive Malassezia infections".)
CLINICAL FEATURES
The term "versicolor" refers to the variable changes in cutaneous pigmentation that may
occur in this disorder. The macules, patches, and thin plaques of tinea versicolor can be
hypopigmented, hyperpigmented, or mildly erythematous ( picture 1A-E). In light-skinned
individuals, hyperpigmented tinea versicolor is often light brown. Hyperpigmented tinea
versicolor may present as dark brown to gray-black macules and patches in those with dark
skin ( picture 2).
The color of affected areas can vary between individuals with similar skin color, and
occasionally, between areas of involvement on one person. Although the reasons for
pigmentary variation are unconfirmed, a few theories have been proposed. Patients with
hypopigmented tinea versicolor often notice that the disorder is most prominent during the
summer, when the affected areas fail to tan after sun exposure. Inhibitory or damaging
effects on melanocytes by azelaic acid (a dicarboxylic acid produced by Malassezia) may play a
role in the development of hypopigmentation [18,19]. Hyperpigmented and erythematous
lesions may be a consequence of an inflammatory reaction to the yeast [18].
A fine scale is often present on affected skin, which becomes more apparent when the lesion
is scraped for microscopy. Individual lesions are typically small, but frequently coalesce into
larger patches. In adolescents and adults, tinea versicolor is most commonly found on the
upper trunk and proximal upper extremities, and less often on the face and intertriginous
areas. In contrast, when tinea versicolor occurs in children, it is likely to involve the face
( picture 3A-B) [1,3].

The distribution of tinea versicolor on the body may reflect the nutritional requirements of
the yeast. Malassezia is lipid-dependent, and the greater sebum production by cutaneous
sebaceous glands on the upper body may contribute to the predominance of tinea versicolor
in this location. This theory may also account for the less frequent occurrence of this disorder
in children and older adults, in whom sebum production is lower [1,2].
While most patients are asymptomatic, some complain of mild pruritus, and many are
concerned about cosmesis. Although spontaneous remission has been reported [20], the
disorder can be persistent if untreated.
Data on dermoscopic findings of tinea versicolor are limited. Frequent dermoscopic findings
appear to be nonuniform pigmentation within lesions, fine scale, and perilesional
hyperpigmentation or hypopigmentation [21-23]. Other features have also been reported
[21-23].
DIAGNOSIS
A diagnosis of tinea versicolor should be suspected when a patient presents with

hypopigmented or hyperpigmented macules coalescing into patches on the upper trunk,
proximal extremities, neck, or face. The variable clinical features of tinea versicolor and the
existence of other skin disorders with similar findings make it preferable to confirm the
diagnosis with a potassium hydroxide (KOH) preparation. Both hyphae and yeast cells are
evident in a pattern that is often described as "spaghetti and meatballs" ( picture 4).
Additionally, in approximately one-third of cases, examination with a Wood's lamp will reveal
yellow to yellow-green fluorescence [17]. (See "Office-based dermatologic diagnostic
procedures", section on 'Potassium hydroxide preparation'.)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of tinea versicolor consists of several common and uncommon skin
disorders. The potassium hydroxide (KOH) preparation is a simple and reliable way to confirm
the diagnosis. Examples of skin disorders that may resemble tinea versicolor include:
● Seborrheic dermatitis – Seborrheic dermatitis on the trunk is usually more

erythematous than tinea versicolor, and typically has thicker scale. Patients often exhibit
other areas of involvement such as the scalp, eyebrows, and nasolabial folds
( picture 5). (See "Overview of dermatitis (eczematous dermatoses)", section on
'Seborrheic dermatitis' and "Seborrheic dermatitis in adolescents and adults", section on
'Clinical manifestations'.)

● Pityriasis rosea – Patients with classic pityriasis rosea present with inflammatory
macules and small patches in a "Christmas tree-like" distribution on the trunk. A larger
herald patch that precedes the widespread eruption is often noted. Lesions are
erythematous and exhibit a collarette of scale ( picture 6). In dark-skinned individuals,
hyperpigmentation can be prominent ( picture 7). (See "Pityriasis rosea".)
● Vitiligo – Vitiligo is characterized by completely depigmented macules and patches

( picture 8). In contrast, tinea versicolor exhibits hypopigmented skin lesions. (See
"Vitiligo: Pathogenesis, clinical features, and diagnosis".)
● Erythrasma – Erythrasma may present with erythematous or hyperpigmented patches

in the axillae or groin, and is included in the differential diagnosis of intertriginous tinea
versicolor ( picture 9A-B). Sites of erythrasma exhibit coral-red fluorescence upon
illumination with a Wood's lamp ( picture 10). (See "Erythrasma".)
● Pityriasis alba – Pityriasis alba is a mild form of eczematous dermatitis that presents
with hypopigmented macules and small patches on the face, and less frequently on the
upper extremities ( picture 11A-B). Fine scale may be visible. The disorder is most
common in children with an atopic history. (See "Acquired hypopigmentation disorders
other than vitiligo", section on 'Pityriasis alba'.)
● Secondary syphilis – Patients with secondary syphilis may present with erythematous
to brown macules, papules, or small plaques in a generalized distribution
( picture 12). Skin involvement is often present on the palms and soles ( picture 13).
(See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients
without HIV", section on 'Clinical manifestations'.)
● Confluent and reticulated papillomatosis of Gougerot and Carteaud – This

uncommon cutaneous disorder usually occurs in young adults. Hyperpigmented, scaly
patches with a reticulated appearance are present ( picture 14A-D). The neck, chest
(particularly intermammary area), and upper back may be affected.
● Mycosis fungoides – Mycosis fungoides may present as hypopigmented patches on the

skin, with a predilection for the trunk and extremities ( picture 15). This variant of the
disorder occurs most commonly in individuals with dark skin. Fine scale, erythema, or
infiltrated plaques may also be present. (See "Clinical manifestations, pathologic
features, and diagnosis of mycosis fungoides".)
● Terra firma-forme dermatosis – Terra firma-forme dermatosis is a benign condition in

which retention hyperkeratosis leads to the appearance of hyperpigmented papules or
plaques that can resemble dirty skin ( picture 16A-B) [24]. Common locations are the
neck and ankle. In contrast to tinea versicolor, lesions are easily removed with an

alcohol swab. (See "Acquired hyperpigmentation disorders", section on 'Terra firma-

forme dermatosis'.)
TREATMENT
Topical therapy is the treatment of choice for patients with tinea versicolor. Systemic therapy
is typically reserved for patients with widespread or recurrent tinea versicolor, or for patients
who have failed topical therapy ( table 1) [25].
High-quality comparative studies on the relative efficacy of specific treatments for tinea
versicolor are limited, making the optimal approach to treatment unclear. A systematic review
and meta-analysis of controlled trials found that most trials that compared treatment
regimens or therapeutic agents were underpowered to detect meaningful differences [26].
The results suggested that longer courses of treatment, higher concentrations of topical
active ingredients, and higher doses of oral antifungals may improve cure rates; however
additional studies are necessary to confirm this conclusion. A table listing common treatment
regimens for tinea versicolor is provided ( table 1).
Patient education — Prior to treatment, patients should be advised that changes in

cutaneous pigment often persist after successful treatment. Restoration of normal
pigmentation may take months after the completion of successful therapy. (See 'Treatment
failure' below.)
First-line therapy — Topical antifungal medications, topical selenium sulfide, and topical zinc
pyrithione are effective and well-tolerated first-line therapies for tinea versicolor ( table 1)
[26].
Topical antifungals — Topical azole antifungals, topical terbinafine, and topical ciclopirox

improve tinea versicolor via direct antifungal activity. Effective treatment regimens ranging
from a few days to four weeks in length are reported in the literature [26]:
● Azole antifungals – Small randomized trials support the efficacy of various topical azole
antifungals ( table 2) [26]. In one randomized trial, ketoconazole 2% cream applied
once daily for 11 to 22 days (mean 14 days) was superior to placebo (84 versus 22
percent achieved mycologic cure) [27]. A typical course of treatment with a topical azole
antifungal is daily application for two weeks.
The shampoo formulation of ketoconazole appears to be effective with a shorter

duration of therapy. The shampoo is applied to affected areas and is washed off after
five minutes. In a randomized trial, a single application of ketoconazole 2% shampoo
was compared with treatment on three consecutive days. Both regimens resulted in
mycologic cure in approximately 80 percent of patients [28].

In accordance with the trial results, we consider both the three-day and one-day
regimens for ketoconazole shampoo reasonable approaches to treatment. However,
given the common location of tinea versicolor in skin sites that are difficult for patients
to see and reach, the potential for environmental or patient-specific factors to influence
the efficacy of treatment, and the minimal risks of treatment, we typically advise
patients to treat for three consecutive days in an attempt to increase the likelihood of
adequate treatment.
● Terbinafine – Topical terbinafine 1% solution applied twice daily for one week has been
proven effective in small randomized trials [29,30].
● Ciclopirox – Topical ciclopirox olamine 1% cream was effective in two small randomized
trials when applied twice daily for 14 days [31].
Selenium sulfide — Topical selenium sulfide exerts antifungal activity primarily through the
promotion of shedding of the infected stratum corneum. In a randomized trial, application of
selenium sulfide 2.5% lotion for 10 minutes for seven days was superior to placebo in
achieving mycologic cure (81 versus 15 percent cured, respectively) [32].
The shampoo formulation of selenium sulfide 2.5% is often prescribed in clinical practice.
Patients apply the shampoo to the affected area daily for one week. The shampoo is rinsed
off after 10 minutes.
A non-prescription selenium sulfide 1% shampoo is also available, but the efficacy of this
product for the treatment of tinea versicolor has not been studied.
Zinc pyrithione — In a controlled trial that included 40 patients with tinea versicolor, zinc
pyrithione 1% shampoo applied for five minutes per day for two weeks was more effective
than placebo for the treatment of tinea versicolor [33]. All patients treated with zinc
pyrithione shampoo were successfully treated compared with none of the patients in the
placebo group.
Severe or recalcitrant disease — Oral therapy is reserved for patients with tinea versicolor
that is refractory to topical therapy or widespread disease that makes the application of
topical drugs difficult [1,25]. It is important to note that persistent dyspigmentation is not a
good indicator of failure of topical therapy. (See 'Treatment failure' below.)
Oral therapies — Oral azole antifungals such as itraconazole and fluconazole are effective
for the treatment of tinea versicolor ( table 1). In contrast to topical terbinafine, oral
terbinafine is not effective [34]. Similarly, griseofulvin cannot be used for this condition.
Systemic therapy is not used as a first-line treatment for limited tinea versicolor to minimize
risk of adverse effects. Abnormalities in liver function tests and drug interactions can occur

with systemic azole antifungals. (See "Pharmacology of azoles", section on 'Adverse effects'
and "Pharmacology of azoles", section on 'Drug interactions'.)
Oral therapy is not typically used for the treatment of tinea versicolor in children.
Itraconazole — Itraconazole therapy for tinea versicolor in adults is usually given as

200 mg per day for five days. Multiple randomized trials have reported mycologic cure rates
between 70 and 100 percent with 200 mg of itraconazole daily for seven days, and dose
comparison studies have shown similar success with treatment durations of five days [35].
Data conflict on the efficacy of a single 400 mg dose of itraconazole. In a randomized, open-
label trial, a single 400 mg dose was as effective as 200 mg daily for seven days [36].
However, a low rate of response to a single 400 mg dose of itraconazole was reported in a
trial that compared single-dose fluconazole and single-dose itraconazole [37].
Fluconazole — Fluconazole for tinea versicolor in adults is typically given as a 300 mg

dose once weekly for two weeks [35]. In a small, uncontrolled study, 300 mg once weekly for
two weeks led to mycologic and clinical cure in 75 percent of patients with tinea versicolor
[38]. A dose-finding randomized trial also supports the efficacy of this regimen; 300 mg once
weekly for up to two weeks resulted in mycologic cure in 87 percent of patients [39].
A single dose of fluconazole may be effective. In an uncontrolled study of 24 individuals with

extensive or recurrent tinea versicolor treated with a single 400 mg dose of fluconazole,
resolution of clinical disease occurred in 74 percent [40].
Other therapies — Additional topical and systemic therapies have been used for the
treatment of tinea versicolor:
● Topical agents – Whitfield ointment [41,42] and sulfur-salicylic acid shampoo [43] are
effective for tinea versicolor, but may cause skin irritation in a minority of patients. Small
uncontrolled studies suggest that propylene glycol [44] and benzoyl peroxide [45] may
also improve tinea versicolor.
● Oral ketoconazole – Although oral ketoconazole was effective for tinea versicolor in
small randomized trials [46,47], life-threatening hepatotoxicity and adrenal
insufficiency, along with multiple potential drug-drug interactions, have been reported
with oral ketoconazole therapy, making it an unfavorable choice for the treatment of
tinea versicolor. Although these adverse effects appear to be rare with the short
duration of therapy used for tinea versicolor [48], knowledge of the potential for
hepatotoxicity and the wide availability of safer oral antifungal agents led the European
Medicines Agency to release a 2013 recommendation that marketing authorizations for
oral ketoconazole be suspended throughout the European Union [49]. The US Food and
Drug Administration (FDA) simultaneously removed its indication for use of the drug for

dermatophyte and Candida infections based upon risks for hepatotoxicity, adrenal
insufficiency, and drug-drug interactions. The FDA also recommended that oral
ketoconazole should not be used as a first-line agent for any fungal infection. The
indications for treatment of blastomycosis, coccidioidomycosis, histoplasmosis,
chromomycosis, and paracoccidioidomycosis have been retained only for patients in
whom other antifungal treatments have failed or are not tolerated [50]. (See
"Pharmacology of azoles", section on 'Adverse effects'.)
In 2016, following an FDA safety review that found continued prescribing of oral
ketoconazole for fungal skin and nail infections, the FDA released a drug safety
communication warning healthcare professionals to avoid prescribing oral
ketoconazole for fungal skin and nail infections [51]. The risks of oral ketoconazole
treatment outweigh the benefits.
Treatment failure — Hypopigmentation and hyperpigmentation can persist for months

following successful treatment of tinea versicolor, and may cause patients to assume
incorrectly that treatment has failed. The presence of scale plus a positive potassium
hydroxide (KOH) preparation is considered indicative of active infection.
Resistance to therapy, frequent recurrence, or widespread disease should prompt

consideration of an immunodeficient state ( table 3).
PREVENTION
Patients who experience frequent recurrences of tinea versicolor (particularly

immunosuppressed individuals) can prevent recurrences with use of topical or oral
preventive therapy, particularly during warm weather. In our clinical experience, prophylaxis
with topical selenium sulfide 2.5% or ketoconazole 2% shampoo applied to the entire body
for ten minutes once per month is an effective therapy.
Oral itraconazole is also used for prophylaxis. In a six-month randomized trial, a greater
percentage of subjects were free of recurrent disease after prophylactic treatment with
itraconazole (200 mg twice daily for one day per month) than with placebo (88 percent versus
57 percent, respectively) [52]. (See 'Other therapies' above.)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Tinea versicolor (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Epidemiology – Tinea versicolor is a common fungal skin infection. The disorder occurs
worldwide, but is most prevalent in tropical climates. Adolescents and young adults are
affected most frequently. Tinea versicolor is not contagious. (See 'Epidemiology' above.)
● Pathogenesis – Malassezia yeasts are a component of normal skin flora. The reasons for
the development of tinea versicolor are likely to be multifactorial, involving both
exogenous and endogenous factors. Immunosuppressed patients may be at increased
risk for the disease. (See 'Pathogenesis and risk factors' above.)
● Clinical features – Patients with tinea versicolor can exhibit hypopigmented,

hyperpigmented, or erythematous macules and patches ( picture 1A-E). The most
common areas of involvement include the upper trunk and proximal upper extremities;
facial and intertriginous areas are less frequently affected ( picture 3A-B). (See 'Clinical
features' above.)
● Diagnosis – The potassium hydroxide (KOH) preparation is a quick and effective way to
diagnose tinea versicolor. A Wood's lamp examination will reveal yellow to yellow-green
fluorescence in a minority of patients. (See 'Diagnosis' above.)
● Treatment:
• General approach – Topical therapy is a safe and effective treatment for most
patients with tinea versicolor. Topical azole antifungals, selenium sulfide, and zinc
pyrithione are effective and well-tolerated topical treatments ( table 1). Patients
should be advised that pigmentary changes may take months to resolve. (See 'First-
line therapy' above and 'Treatment failure' above.)
• Patients with extensive disease – For adult patients with extensive disease, we
suggest treatment with an oral azole antifungal rather than topical therapy
( table 1) (Grade 2B). (See 'Severe or recalcitrant disease' above.)
• Patients with recalcitrant disease – Patients with tinea versicolor who fail topical
therapy can be treated with a systemic agent. Treatment regimens are the same as
for patients with extensive disease. (See 'Severe or recalcitrant disease' above.)
• Patients with frequent recurrences – Recurrent disease is common. For patients

who desire treatment and experience multiple recurrences per year, we suggest
prophylactic therapy (Grade 2B). We typically use once-monthly application of
selenium sulfide or ketoconazole shampoo. If this regimen is not effective, we
prescribe 400 mg of itraconazole (in two divided doses) once monthly for adults
during the warm months of the year, when recurrence is most likely. (See
'Prevention' above.)
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47. Zaias N. Pityriasis versicolor with ketoconazole. J Am Acad Dermatol 1989; 20:703.
48. Goodless DR, Ramos-Caro FA, Flowers FP. Ketoconazole in the treatment of pityriasis
versicolor: international review of clinical trials. DICP 1991; 25:395.
49. European Medicines Agency. European Medicines Agency recommends suspension of m
arketing authorisations for oral ketoconazole. www.ema.europa.eu/ema/index.jsp?curl=
pages/news_and_events/news/2013/07/news_detail_001855.jsp&mid=WC0b01ac058004
d5c1 (Accessed on July 26, 2013).
50. US Food and Drug Administration. FDA Drug Safety Communication: FDA limits usage of
Nizoral (ketoconazole) oral tablets due to potentially fatal liver injury and risk of drug int
eractions and adrenal gland problems. www.fda.gov/Drugs/DrugSafety/ucm362415.htm
(Accessed on July 26, 2013).
51. www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProduc
ts/ucm502073.htm (Accessed on May 23, 2016).
52. Faergemann J, Gupta AK, Al Mofadi A, et al. Efficacy of itraconazole in the prophylactic
treatment of pityriasis (tinea) versicolor. Arch Dermatol 2002; 138:69.
Topic 4039 Version 23.0

GRAPHICS
Tinea versicolor
Multiple mildly erythematous, thin plaques on the upper trunk and proximal upper extremities.
Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.
Graphic 100026 Version 4.0

Tinea versicolor
Multiple hyperpigmented, coalescing macules and thin plaques on the chest.

Tinea versicolor
Mildly erythematous macules, patches, and thin plaques on the chest.

Tinea versicolor
Hyperpigmented macules and patches on the neck.

Tinea versicolor
Multiple hypopigmented macules on the neck, shoulder, and chest.

Therapeutic regimens for tinea versicolor (pityriasis versicolor)
Drug Dose Duration
Topical therapies
Various azole antifungal Once- or twice-daily Typically two weeks (range in

preparations (including application clinical studies of one to four
creams, solutions, lotions, weeks)
foams, and gels)*
Ketoconazole 2% shampoo One five-minute application Three consecutive days (a

daily single application may be
similarly effective)
Terbinafine 1% cream Twice-daily application One week
Ciclopirox 0.77% cream Twice-daily application Two weeks
Selenium sulfide 2.5% One ten-minute application One week

shampoo daily
Zinc pyrithione 1 or 2% One five-minute application Two weeks

shampoo daily
Oral therapies ¶
Fluconazole 300 mg orally once weekly Two weeks
Itraconazole 200 mg orally once daily Five days
* Topical azole antifungals include: clotrimazole 1%, econazole 1%, efinaconazole 10%,
ketoconazole 2%, luliconazole 1%, miconazole 2%, oxiconazole 1%, sertaconazole 2%, and
sulconazole 1%. For additional detail on available formulations and frequency of application refer
to the Lexicomp drug-specific monographs included with UpToDate.
¶ Oral therapy is reserved for patients with disease refractory to topical therapy or widespread
disease that makes the application of topical therapy difficult. Oral terbinafine and griseofulvin
are not effective; oral ketoconazole is not recommended (refer to topic discussion). Doses
provided are for adults.
Prepared with data from: Hu SW, Bigby M. Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010;
146:1132.

Tinea versicolor chest
Hyperpigmented macules and patches are present on the chest in

this patient with tinea versicolor.
Photo courtesy of Paul S Matz, MD. Reproduced from: Chung EK, Boom JA, Datto GA,
Matz PS (Eds). Visual Diagnosis in Pediatrics. Philadelphia: Lippincott Williams &
Wilkins, 2006. Copyright © 2006.

Tinea versicolor
Hypopigmented macules on the face of a child.

Tinea versicolor
Hypopigmented macules on the face and neck of a child.

Microscopic tinea versicolor
Potassium hydroxide preparation of tinea versicolor demonstrating short hyphae and yeast cells.

Seborrheic dermatitis
Facial redness and scale involving the nasolabial folds and central
face.
Reproduced with permission from: Goodheart HP. Goodheart's photoguide of

common skin disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
Copyright © 2003 Lippincott Williams & Wilkins.

Pityriasis rosea
Erythematous papules and oval plaques are present on the trunk. A larger herald patch is on the right
midback.

Pityriasis rosea
Pityriasis rosea. Here the "Christmas tree" pattern is evident.
Reproduced with permission from: Goodheart HP. Goodheart's Photoguide of

Common Skin Disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
Copyright © 2003 Lippincott Williams & Wilkins.

Generalized vitiligo
This patient has generalized vitiligo with extensive involvement.
Reproduced with permission from: Goodheart HP. Goodheart's Photoguide of

Common Skin Disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
Copyright ©2003 Lippincott Williams & Wilkins.

Erythrasma
This 40-year-old male patient with diabetes presented with red-

brown patches in the axillae that resolved with erythromycin
therapy.
Copyright © Jayakar Thomas, MD, PhD, Dermatlas; http://www.dermatlas.org.

Erythrasma
Red-brown plaques of erythrasma in the groin.
Reproduced with permission from John L Aeling, MD.

Erythrasma under light from a Wood's lamp
Examination with a Wood's lamp reveals coral red fluorescence on

the inner thighs of this patient with erythrasma.
Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights

reserved.

Pityriasis alba
Hypopigmented macules are present on the face of this young

patient with pityriasis alba.
Copyright © Nicole Sorensen, RN, Dermatlas; http://www.dermatlas.org.

Pityriasis alba
Pityriasis alba. Hypopigmented, slightly scaly macules are present

on this child's cheeks.
Reproduced with permission from: Stedman's Medical Dictionary. Copyright © 2008

Lippincott Williams & Wilkins.

Secondary syphilis
Multiple slightly scaly, erythematous papules are present on the

trunk of this patient with papular secondary syphilis.

reserved.

Secondary syphilis
Maculopapular rash on the palms, which rarely can be pustular, in a

patient with secondary syphilis. Patients can be quite contagious at
this stage.
Courtesy of David H Martin and Tomasz F Mroczkowski. The Skin and Infection: A
Color Atlas and Text, Sanders CV, Nesbitt LT Jr (Eds), Williams & Wilkins, Baltimore,
1995.
http://www.lww.com

Confluent and reticulated papillomatosis
Reticulated, hyperpigmented patches and thin plaques with fine

scale are present on the upper back.

reserved.

Reticulated, hyperpigmented patches and thin plaques with mild

scale are present on the chest and inframammary areas.

reserved.

Close view of hyperpigmented, reticulated thin plaques in confluent

reticulated papillomatosis.

reserved.

Confluent and reticulated papillomatosis of

Gougerot and Carteaud
Hyperpigmented, scaly papules and plaques on the trunk, which

become reticulated toward the periphery, are present.
Figure used with permission from Andrew Montemarano, DO. Reproduced from:
Wolff K, Goldsmith LA, Katz S, et al. Fitzpatrick's Dermatology in General Medicine,
7th ed, McGraw-Hill Professional 2008. Copyright © 2008 Andrew Montemarano, DO.

Hypopigmented mycosis fungoides
Hypopigmented patches are present in this patient with mycosis

fungoides.

reserved.

Terra firma-forme dermatosis
(A) Brown-gray, pigmented patches on the abdomen with islands of normal skin.
(B) Remarkable response to wiping of pigmented patches with a gauze pad saturated with isopropyl alcoh
Reproduced with permission from: Erkek E, Sahin S, Çetin ED, Sezer E. Terra firma-forme dermatosis. Indian J Dermatol Venereol Le
2012 Scientific Scholar.

Terra firma-forme dermatosis
Thick, reticulated, brown plaques on the back of a 20-year-old man with terra firma-forme dermatosis. No
skin in the areas wiped with 70% ethyl alcohol.
Reproduced with permission from: Erkek E, Sahin S, Çetin ED, Sezer E. Terra firma-forme dermatosis. Indian J Dermatol Venereol Le
2012 Scientific Scholar.

Topical antifungal agents
Drug Dose How supplied*
Azoles ¶
Clotrimazole Δ Twice per day Cream 1%
Ointment 1%
Solution 1%
Econazole Once per day (twice per day for Cream 1%

candidiasis)
Foam 1%
Efinaconazole ◊ Once per day Solution 10%
Ketoconazole Once per day Cream 2%
Shampoo 2% (1% shampoo is

available over the counter)
Gel 2%
Foam 2%
Luliconazole Once per day Cream 1%
Miconazole Δ Twice per day Cream 2%
Ointment 2%
Solution 2%
Powder 2%
Aerosol solution 2%
Aerosol powder 2%
Oxiconazole Once to twice per day Cream 1%
Lotion 1%
Sertaconazole Twice per day Cream 2%
Sulconazole Once or twice per day Cream 1%
Solution 1%
Allylamines §
Naftifine Once per day (cream), twice Cream 1%

per day (gel)
Cream 2%
Gel 1%
Gel 2%
Terbinafine Δ Once to twice per day Cream 1%
Spray solution 1%

Benzylamine §
Butenafine Δ Once per day (twice per day for Cream 1%

tinea pedis)
Polyene: Treats Candida infections only
Nystatin 2 to 3 times per day Cream 100,000 units/gram
Ointment 100,000 units/gram
Powder 100,000 units/gram
Other
Ciclopirox ¥ Twice per day Cream 0.77%
Gel 0.77%
Suspension 0.77%
Shampoo 1%
Solution 8%
Tolnaftate Δ ‡ Twice per day Cream 1%
Powder 1%
Aerosol:
Liquid 1%
Powder 1%
Solution 1%
For additional details on available formulations and frequency of application, refer to the
Lexicomp drug-specific monographs included with UpToDate.
* Preparations available in the United States and some other countries.
¶ Azoles have activity against dermatophytes, tinea versicolor, and Candida. Sulconazole,
oxiconazole, and luliconazole may be less effective for Candida infection than other azoles.
Δ Available in over-the-counter (nonprescription) preparations in the United States and some

other countries.
◊ Indicated for onychomycosis.
§ Can treat Candida in addition to dermatophytes and tinea versicolor but may be less effective
than azoles and ciclopirox for Candida infection.
¥ Treats dermatophytes, tinea versicolor, and Candida.
‡ Does not treat Candida; less effective than other options for dermatophytes.
Prepared with data from: US Food & Drug Administration (FDA) approved product information. US National Library of
Medicine. (Available online at: https://dailymed.nlm.nih.gov/dailymed/).


Conditions associated with secondary immunodeficiency
Immunosuppressive therapy
Cytotoxic chemotherapy for malignancy
Treatment of autoimmune disease
Bone marrow ablation prior to transplantation
Treatment or prophylaxis of graft-versus-host disease following bone marrow transplantation
Treatment of rejection following solid organ transplantation
Microbial infection
Viral infection
HIV, AIDS
Measles
Herpes group viruses (HSV 1 or 2, EBV, CMV, VZV)
Bacterial infection (superantigens)
Mycobacterial infection
Parasitic infestation
Malignancy
Hodgkin disease
Chronic lymphocytic leukemia
Multiple myeloma
Solid tumors
Disorders of biochemical homeostasis
Diabetes mellitus
Renal insufficiency/dialysis
Hepatic insufficiency/cirrhosis
Malnutrition
Autoimmune disease
Systemic lupus erythematosus
Rheumatoid arthritis
Trauma
Burns
Environmental exposure
Radiation

Ionizing
Ultraviolet
Toxic chemicals
Other
Pregnancy
Stress*
Asplenia/hyposplenism
Allogeneic blood transfusion
Aging ¶
HIV: human immunodeficiency virus; AIDS: acquired immunodeficiency syndrome; HSV 1/2:
herpes simplex viruses 1 or 2; EBV: Epstein-Barr virus; CMV: cytomegalovirus; VZV: varicella-zoster
virus.
* Stress has been associated with an increased risk of infection, perhaps due to the effects of the
endogenous stress cortisol response on the immune system.
¶ Aging has been associated with relative immunodeficiency, with reductions in cellular and

humoral adaptive immune responses. Refer to the UpToDate topic on immune function in older
adults.

Contributor Disclosures
Beth G Goldstein, MD Equity Ownership/Stock Options: Skinvest, Inc [Skincare]. All of the relevant
financial relationships listed have been mitigated. Adam O Goldstein, MD, MPH No relevant financial
relationship(s) with ineligible companies to disclose. Robert P Dellavalle, MD, PhD, MSPH Equity
Ownership/Stock Options: Altus Labs [Itch, eczema]. Grant/Research/Clinical Trial Support: Pfizer
[Patient decision aids, inflammatory and immune-mediated skin disease]. Other Financial Interest:
Cochrane Council meetings [Expense reimbursement]. All of the relevant financial relationships listed
have been mitigated. Moise L Levy, MD Grant/Research/Clinical Trial Support: Castle Creek Biosciences
[Epidermolysis bullosa]; Janssen Pharmaceuticals [Psoriasis]; Krystal Biotech [Epidermolysis bullosa];
Regeneron Pharmaceuticals [Atopic dermatitis]. Consultant/Advisory Boards: Abeona Therapeutics
[Epidermolysis bullosa]; Castle Creek Biosciences [Epidermolysis bullosa]; Novan [Molluscum
contagiosum treatment]; Regeneron Pharmaceuticals [Atopic dermatitis]. Other Financial Interest:
Mayne Pharma [Data and safety monitoring board for ichthyosis trial]. All of the relevant financial
relationships listed have been mitigated. Ted Rosen, MD Consultant/Advisory Boards: Almirall [Actinic
keratosis]; Beiersdorf [Dry skin]; DermTech [Melanoma]. All of the relevant financial relationships listed
have been mitigated. Abena O Ofori, MD No relevant financial relationship(s) with ineligible companies
to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for references
to be provided to support the content. Appropriately referenced content is required of all authors and
must conform to UpToDate standards of evidence.
Conflict of interest policy

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7/7/23, 21:20 Tinea versicolor (pityriasis versicolor) - UpToDate

Official reprint from UpToDate®

Literature review current through: Jun 2023.

PATHOGENESIS AND RISK FACTORS

Malassezia is a lipid-dependent, dimorphic fungus that is a component of normal skin flora.

M. globosa appears to be the predominant causal species in tinea versicolor [14-16]. M.

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A diagnosis of tinea versicolor should be suspected when a patient presents with

● Seborrheic dermatitis – Seborrheic dermatitis on the trunk is usually more

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● Vitiligo – Vitiligo is characterized by completely depigmented macules and patches

● Erythrasma – Erythrasma may present with erythematous or hyperpigmented patches

● Confluent and reticulated papillomatosis of Gougerot and Carteaud – This

● Mycosis fungoides – Mycosis fungoides may present as hypopigmented patches on the

● Terra firma-forme dermatosis – Terra firma-forme dermatosis is a benign condition in

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alcohol swab. (See "Acquired hyperpigmentation disorders", section on 'Terra firma-

Patient education — Prior to treatment, patients should be advised that changes in

Topical antifungals — Topical azole antifungals, topical terbinafine, and topical ciclopirox

The shampoo formulation of ketoconazole appears to be effective with a shorter

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Itraconazole — Itraconazole therapy for tinea versicolor in adults is usually given as

Fluconazole — Fluconazole for tinea versicolor in adults is typically given as a 300 mg

A single dose of fluconazole may be effective. In an uncontrolled study of 24 individuals with

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Treatment failure — Hypopigmentation and hyperpigmentation can persist for months

Resistance to therapy, frequent recurrence, or widespread disease should prompt

Patients who experience frequent recurrences of tinea versicolor (particularly

INFORMATION FOR PATIENTS

● Basics topics (see "Patient education: Tinea versicolor (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Clinical features – Patients with tinea versicolor can exhibit hypopigmented,

• Patients with frequent recurrences – Recurrent disease is common. For patients

Use of UpToDate is subject to the Terms of Use.

3. Bouassida S, Boudaya S, Ghorbel R, et al. [Pityriasis versicolor in children: a retrospective

9. Faergemann J. Pityriasis versicolor. Semin Dermatol 1993; 12:276.

https://www.uptodate.com/contents/tinea-versicolor-pityriasis-versicolor/print?search=tiña de la cabeza&topicRef=4030&source=see_link 10/47

14. Morishita N, Sei Y. Microreview of Pityriasis versicolor and Malassezia species.

16. Karakaş M, Turaç-Biçer A, Ilkit M, et al. Epidemiology of pityriasis versicolor in Adana,

17. Schwartz RA. Superficial fungal infections. Lancet 2004; 364:1173.

19. Nazzaro-Porro M, Passi S. Identification of tyrosinase inhibitors in cultures of

https://www.uptodate.com/contents/tinea-versicolor-pityriasis-versicolor/print?search=tiña de la cabeza&topicRef=4030&source=see_link 11/47

33. Fredriksson T, Faergemann J. Double-blind comparison of a zinc pyrithione shampoo and

https://www.uptodate.com/contents/tinea-versicolor-pityriasis-versicolor/print?search=tiña de la cabeza&topicRef=4030&source=see_link 12/47

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Graphic 100026 Version 4.0

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Multiple hyperpigmented, coalescing macules and thin plaques on the chest.

Graphic 100022 Version 4.0

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Mildly erythematous macules, patches, and thin plaques on the chest.

Graphic 100020 Version 2.0

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Hyperpigmented macules and patches on the neck.

Graphic 100019 Version 2.0

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Multiple hypopigmented macules on the neck, shoulder, and chest.

Graphic 100021 Version 3.0

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Therapeutic regimens for tinea versicolor (pityriasis versicolor)

Drug Dose Duration