diagnosis and treatment

Last edited 06/2020 and last reviewed 07/2023

Diagnosis is usually clinical (1).

Scrapings fluoresce bright yellow to coppery orange/gold colour under Wood's lamp (1,2).

  • is seen only in one third of cases
  • aids in differentiation of this condition from vitiligo
  • often the areas adjacent to the lesions may also fluoresce, indicating the spread of infection (2)

Samples of skin scale can be used to confirm the diagnosis - these have a 'spaghetti and meatball' appearance (presence of both hyphae and spores) on potassium hydroxide wet-mount examination. There is no value in fungal culture in this condition because the organism is part of normal flora and isolation does not prove pathogenicity (2,3).

Treatment

Topical preparations are frequently used and include both nonspecific and specific antifungal agents.

  • nonspecific agents- act by physically or chemically removing the infected stratum corneum without having direct antifungal activity (1). - for example:
    • selenium sulphide suspension (2.5%) - Selsun shampoo –
      • applied once a day to the affected areas, leave it on for 10 -15 minutes; before thoroughly rinsing of
      • used for 7days
      • it is an effective treatment, but some patients do not like the smell - this is an unlicensed indication (1)
        • propylene glycol - is a keratolytic agent often used as a base in other topical preparations but has been shown to be effective
  • specific topical antifungal agents
    • miconazole cream - especially if patches are limited - applied once daily for three weeks
    • ketoconazole is the most commonly used topical agent (1)
      • available as a cream or shampoo. Ketoconazole 2% shampoo has been shown to be effective when applied daily for 1, 3, or 14 days (1)
    • terbinafine, an allylamine that is offered as a 1% cream or spray, has also been successful when applied twice daily for 7 days (3)

Systemic treatment should be reserved for the few patients with very extensive disease. A suitable regimen is itraconazole 200 mg daily for seven days. Griseofulvin and oral terbinafine are generally ineffective in this condition (3). Systemic therapy with ketoconazole is also a treatment option (3,1)

Infection commonly leads to hypopigmentation of the skin. This hypopigmentation associated with this infection may persist for months after successful treatment (3,1) and a common mistake is to confuse it with a relapse. Warn patients that it will take several months for the skin colour to returns to its original state - on occasions the discoloration can be very persistent (4). Successful eradication may not be confirmed until further tanning of the skin occurs.

  • while a mycological cure can be achieved, normal pigmentation of the affected areas might not return for months after treatment cessation. Patients should be advised to avoid prolonged sun exposure during this time, as tanning will enhance the contrast between affected areas and normal skin
  • recurrence of tinea versicolor is not uncommon. For patients with frequent relapses, prophylactic treatment might be required. Effective options include monthly treatments of oral itraconazole (a single 400-mg dose) (3); also patient should continue using the ketoconazole shampoo once every two to four weeks for approximately six months in order to try and prevent recurrence (4)

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