Pityriasis versicolor (PV), also known as tinea versicolor, is caused by Malassezia species. This condition is one of the most common superficial fungal infections worldwide.

This may be triggered by various factors, including humidity and high temperature, hyperhidrosis, familial susceptibility, and immunosuppression. Consequently, PV occurs more frequently in tropical climates (as much as 40%) as compared to temperate climates.

Patients with PV present with well-demarcated round or oval macules on the trunk, neck, and upper arms where the density of sebaceous glands is high. These lesions often appear hyperpigmented on lighter skin types and hypopigmented in darker or tanned skin and can vary in color. Smaller macules may have a powdery appearance due to flaking skin, although flaking may only manifest on the edges of larger lesions.

PV is generally asymptomatic, although some patients experience mild pruritus.

PV is difficult to cure and the chances for relapse or recurrent infections are high as high as 80% within 2 years due to the presence of Malassezia in the normal skin flora.

TAKE HOME MESSAGE

This review focuses on the clinical evidence supporting the efficacy of antifungal treatment for PV.

Clinical investigations have demonstrated the clinical efficacy of various topical antifungal medications in treating PV including topical ketoconazole, terbinafine and zinc pyrithione. The advantage to topical treatments is that they are fast-acting and well-tolerated. There is less risk of serious adverse effects and limited drug interactions. 

Ketoconazole, an imidazole, was the first broad-spectrum antifungal used in the treatment of superficial and systemic mycoses. Based on the accumulated evidence, treatment once or twice daily for 14 days with topical ketoconazole cream or foam, and once weekly use of ketoconazole shampoo may be effective treatment for PV.

Similarly, topical terbinafine cream should be applied twice daily for 7 days.

In cases of severe or recalcitrant PV, the oral antifungal medications itraconazole and fluconazole may be more appropriate, with pramiconazole a possible future option.

Oral terbinafine is not effective in treating PV and oral ketoconazole should no longer be prescribed.

Maintenance, or prophylactic, therapy may be useful in preventing recurrent infection.