AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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INTRODUCTION

Section 2 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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Background

Tinea versicolor (tin'-eah verse'-ih-color) is a common, benign, superficial, cutaneous fungal infection characterized by scaly hypopigmented or hyperpigmented macules that are located primarily on the chest and back. Patients occasionally report pruritus; otherwise, the condition is asymptomatic and is not contagious. This condition results from an overgrowth of Malassezia furfur, which is part of normal skin flora and produces color changes only when it flourishes beyond normal levels.

M furfur is a dimorphic lipophilic organism that is cultured only in media enriched with C12- or C14-sized fatty acids. Historically, the name M furfur was used to designate the fungal pathogen of tinea versicolor before it is grown in culture.

The study of Malassezia species has always been complicated. The confusion is due to different forms and different growth requirements. With the advent of DNA sequencing, much of this confusion was found to be caused by the presence of numerous very similar but different species (both pathogenic and nonpathogenic). Malassezia is able to exist in both yeast and mycelial forms, with yeast most commonly associated with normal skin. Some species appear to be more common in certain areas of the world, and some are more likely to be pathogenic in one area and not in another. Studies of Malassezia are of little value unless the specific species is identified using DNA sequencing. Many of the prior studies testing therapy efficacy showed significant failure rates or recurrences. Some of these may be explained by the existence of these varied species.

Much of the confusion was resolved with the taxonomic revision in 1996, based on sequencing of the large-subunit rRNA and nuclear DNA of more than 100 isolates of Malassezia species. The genus Malassezia was revised to include 7 species: Malassezia globosa, Malassezia sympodialis, M furfur, Malassezia slooffiae, Malassezia pachydermatis, Malassezia restricta, and Malassezia obtusa. Additional uncommon species have been identified using these or similar techniques. The clinical significance of each of these species continues to be studied. A study of the epidemiology of Malassezia yeasts associated with pityriasis (tinea) versicolor in Ontario, Canada, revealed the most frequently isolated species included M sympodialis, M globosa, and M furfur, accounting for 59.4%, 25.2%, and 10.8% of the isolated etiological agents, respectively.

An October 2000 study in the British Journal of Dermatology reported the spherical yeasts observed in vivo were morphologically identical to the globose yeasts characteristic of M globosa. In culture, M globosa was found in 97% of cases, alone in 60% of cases, associated with M sympodialis in 29% of cases, and associated with M slooffiae in 7% of cases. M sympodialis and M slooffiae were found in similar percentages on clinically uninvolved skin of the trunk, whereas M globosa was not isolated at other sites. This strongly suggests that M globosa, in its mycelial phase, is the causative agent of tinea versicolor. This result must still be confirmed in other worldwide studies.

Because of this confusion of names, M furfur is commonly used to refer generically to the etiologic agent of tinea versicolor. Despite disagreement about the names, tinea versicolor results from a shift in the relationship between a resident yeast flora and its host.

M furfur does not attack the hair shaft, nails, or mucous membranes. The infection is localized to the stratum corneum and chronically recurs in predisposed patients. It is more common during warmer months and in warmer climates. Sun exposure frequently makes the lesions more apparent. In temperate climates, patients develop the disease in the spring and summer. In the tropics, patients are more likely to have tinea versicolor throughout the year. Although rare in children younger than 12 years, tinea versicolor is common in adolescents and young adults. Beyond age 40 years, lipid levels in the skin gradually decrease, and tinea versicolor becomes uncommon.

Although M furfur is a component of normal flora, it is also an opportunistic pathogen. The organism is considered a possible factor in other cutaneous diseases, including Pityrosporum folliculitis, confluent and reticulate papillomatosis, seborrheic dermatitis, the provocation of psoriatic lesions, and some forms of atopic dermatitis. Studies also show that tinea versicolor occurs with malnutrition and various diseases, including Cushing syndrome. Pregnancy and oral contraceptives may influence susceptibility, but firm data are lacking. Patients with AIDS may present with severe seborrhea but do not have a higher incidence of tinea versicolor. Systemic infections are attributed to Pityrosporum in extremely rare cases.

M furfur is not a dermatophyte, does not grow on dermatophyte test media (DTM), and does not respond to griseofulvin therapy. Many treatments are effective in clearing infection and preventing recurrence. Selenium sulfide shampoo (eg, Selsun), ketoconazole shampoo, and other topical or oral therapies that contain azole antifungals are effective.

Pathophysiology

Skin lesions are either hypopigmented or hyperpigmented. In patients with hypopigmentation, tyrosinase inhibitors competitively inhibit an enzyme necessary for melanocyte pigment formation. In hyperpigmented macules, the organism induces enlargement of melanosomes made by melanocytes in the basal layer of the epidermis.

The nutritional requirement of M furfur is one of the most important factors that affect the growth of the organism on the skin. Studies show that lesion sites have a decrease in sebaceous gland secretions and water content, along with an increase in pH value compared with normal skin. M furfur is lipophilic, and the mycelial stage of M furfur can be induced in vitro by the addition of cholesterol and cholesterol esters to the appropriate medium. However, significantly more amino acids are extracted from the skin of infected patients, suggesting that amino acids, rather than lipids, are critical for the development of the disease. In vitro, the amino acid asparagine stimulates the growth of the organism, while glycine induces hyphal formation.

Patient immune response also affects infection. Studies suggest a reduced body response to the specific fungal elements that produce tinea versicolor. In various studies, defects in lymphokine production and natural killer T cells were found; phytohemagglutinin (PHA) and concanavalin A (Con A) stimulation was decreased; and interleukin (IL)–2, IL-10, and interferon (IFN)–g production by lymphocytes was decreased in affected patients. The exact pathophysiology of this disorder remains undefined, and additional studies are needed.

Frequency

United States

Depending on the method and sensitivity of sampling methods, Malassezia species may be found in as many as 18% of infants and 90-100% of adults. Clinical tinea versicolor is more common in areas with higher temperatures and higher relative humidities. The incidence of this condition is approximately 2-8% of the population. The exact incidence is difficult to assess because many affected individuals may not seek medical attention.

International

Tinea versicolor occurs worldwide, with an incidence rate of 50% in the humid hot environment of Western Samoa and 1.1% in the colder environment of Sweden. In temperate zones, the onset occurs during the warmer months of the year, and the lesions generally fade in the cooler and drier months. In tropical countries, where heat and high humidity are more continuous, people develop more extensive and persistent disease.

Mortality/Morbidity

Tinea versicolor is a benign skin disease. Morbidity results primarily from the discoloration. The adverse cosmetic effect of lesions may lead to significant emotional distress, particularly in adolescents. Tinea versicolor frequently recurs despite adequate initial therapy. Even with adequate therapy, residual pigmentary changes may take several weeks to resolve.

The yeasts of the genus Malassezia have been associated with a number of other diseases that affect the human skin, such as Malassezia (Pityrosporum) folliculitis, seborrheic dermatitis, atopic dermatitis, psoriasis, confluent and reticulated papillomatosis, onychomycosis, and transient acantholytic dermatosis.

Race

Although tinea versicolor is usually more apparent in darker-skinned individuals, the incidence of tinea versicolor appears to be the same in all races.

Sex

Females and males are equally affected.

Age

In temperate zones (including most of the United States), tinea versicolor is rare in children. Affected infants or children often have an atypical presentation. In temperate areas, the disorder is common in young adults aged 17-24 years. In tropical climates, tinea versicolor is more common in all age groups, but most cases occur in individuals aged 10-19 years.

CLINICAL

Section 3 of 11  

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• Clinical
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• Follow-up
• Miscellaneous
• Multimedia
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History

Questioning the patient about skin or systemic diseases, current therapy, and drug allergies provides guidance in selecting an appropriate therapy. The following are factors that may be used to guide therapy:

• Other diseases, including renal disease, hepatic disease, and endocrine disease (eg, diabetes mellitus)
• History of HIV or other immunocompromising disorder, which can increase the severity of tinea versicolor
• Other skin disorders, including personal or family history of atopy or other eczematous conditions
• Current or recent topical or systemic therapy
• Drug allergies
• Seasonal variations in skin color
• Use of some body oils, which may supply additional nutrients to the M furfur
• Sweat associated with exercise, which may contribute to disease development and recurrence

Physical

• Lesion characteristics
• • Lesions occur in various colors and shapes, as the name implies (versi means several).
  • Lesions are either macules or very superficial papules with fine scale that may not be evident except on close examination.
  • Even when scale is not apparent, when the skin is wiped with a wet cloth and scraped for examination, it yields a surprising amount of dirty-brown keratin. If not, the areas of dyschromia may represent residual effects of previously treated tinea versicolor.
  • Occasionally, determining whether the lighter or darker skin is affected is difficult.
  • Lesions have relatively sharp margins and may be lighter or darker than the normal skin color. The lesions are frequently a light orange or tan color in light-skinned individuals.
  • The color of lesions varies from individual to individual, but each individual's lesions are approximately the same color.
  • Lesions are evenly pigmented. The inflammatory border, relative central clearing, and erythema seen in most fungal infections are lacking.
  • Small lesions are usually circular or oval.
  • Confluent patches with scattered circular or oval macules around the edges are common.
  • Other lesions may be large enough to cover most of the trunk.
  • Lesions are usually asymptomatic but may be mildly pruritic. The pruritus is more intense when the patient is excessively warm.
  • Residual hypopigmentation, without overlying scale, may remain for many months following effective treatment. These areas may become more apparent following sun exposure, causing the patient to incorrectly suspect that the infection has recurred.
• Lesion distribution
• • The upper trunk is most commonly affected, but the lesions often spread to the upper arms, antecubital fossae, neck, abdomen, and popliteal fossae.
  • Lesions in the axillae, groin, thighs, and genitalia are less common.
  • Facial, scalp, and palmar lesions occur in the tropics but are rare in temperate zones.
  • In some patients, tinea versicolor primarily affects the flexural regions, the face, or isolated areas of the extremities. This unusual pattern of tinea versicolor is seen more often in immunocompromised hosts and can be confused with candidiasis, seborrheic dermatitis, psoriasis, erythrasma, and dermatophyte infections.
  • Lesions that are imperceptible or doubtful are more visible using a Wood lamp in a darkened room.

Causes

• M furfur is now the most commonly accepted name for the organism that causes tinea versicolor. Thus, Pityrosporum orbiculare, Pityrosporum ovale, and Malassezia ovalis are synonyms for M furfur.
• Despite disagreement about the names, tinea versicolor results from a shift in the relationship between a human and a resident yeast flora.

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Acanthosis nigricans
Confluent and reticulated papillomatosis of Gougerot and Carteaud
Cutaneous T-cell lymphoma
Erythrasma
Psoriasis (guttate)
Seborrheic dermatitis
Tinea corporis
Vitiligo

• Vitiligo and chloasma are normally distinguished by a complete absence of scaling.
• Seborrheic dermatitis, pityriasis rosea, secondary syphilis, pinta, and tinea corporis show more inflammatory change than tinea versicolor.
• Erythrasma may closely mimic tinea versicolor with pigmentary change and scaling, but satellite lesions are less common, and erythrasma fluoresces pink under a Wood lamp.

WORKUP

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Lab Studies

• The diagnosis is usually made based on clinical examination findings; however, the diagnosis is easily confirmed with microscopic examination of scales soaked in 10%-15% potassium hydroxide (KOH).
• Microscopic examination
• • Microscopic examination demonstrates the characteristic thick-walled spherical or oval yeast forms and coarse septate mycelium, often broken up into short filaments.
  • This combination of mycelium strands and numerous spores is commonly referred to as "spaghetti and meatballs."
  • Liquid blue ink, methylene blue, or Swartz-Medrik stain can be added to the KOH preparation for better visualization of the causative organism.
  • Scales may also be removed using clear adhesive tape; they are then directly examined. The tape must be clear and is pressed several times over involved areas of skin. The tape is then lightly pressed, sticky side down, onto a microscope slide. A small drop of methylene blue or other appropriate stain is placed at the edge of the tape and allowed to run between the tape and the glass slide. Spores, often in grapelike clumps, and mycelium are easily seen.
• Cultures
• • M furfur is a dimorphic lipophilic organism, which is cultured only in media enriched with C12- to C14-sized fatty acids. It is not a dermatophyte, does not grow on DTM, and does not respond to griseofulvin therapy.
  • If inoculated into lipid-rich media, the scales of tinea versicolor show spherical yeasts that produce the mycelial phase of the normal flora yeast P orbiculare. Scales that show mycelium and clusters of oval yeasts on direct microscopy grow P ovale on culture.
  • Colonization by M furfur is especially dense in the scalp, the upper trunk, and the flexures. In patients with clinical disease, the organism occurs in both the filamentous (hyphal) and the yeast (spore) stage forms.

Histologic Findings

The characteristic histological changes include hyperkeratosis, parakeratosis, and slight acanthosis with a mild perivascular inflammatory infiltrate in the upper dermis. The organism is usually present in the upper layers of the stratum corneum, and electron microscopy reveals invasion between and within the keratinized cells. In addition to the common findings noted above, acanthosis nigricans–like changes have been reported in more papular lesions, and dilated blood vessels are prominent in erythematous lesions. M furfur is detected by hematoxylin and eosin (H and E) stain alone, although periodic acid-Schiff (PAS) or methenamine-silver staining facilitates detection.

TREATMENT

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Medical Care

The disease is easily treated, and skin color alterations usually resolve within a few months of treatment. It does not leave any permanent scars or pigment changes.

Topical therapy alone is indicated for most patients. Systemic treatment is indicated for extensive involvement, for recurrent infections, or when topical therapy has failed. Because treatment is relatively easy and recurrence is common, therapy must be as safe, inexpensive, and convenient as possible. A plan for prophylactic therapy should be discussed with all patients to reduce the high recurrence rate.

Although this relatively benign disorder can be treated easily and cheaply, more than 300 articles regarding tinea versicolor have appeared in recent medical literature. Many of the newer antifungal products are effective against M furfur; however, justifying the cost or risk associated with many of these medications is difficult.

Remember that tinea versicolor does not respond to griseofulvin.

• Topical agents
• • Effective topical agents include selenium sulfide (eg, Selsun shampoo), azole antimycotics, ciclopirox olamine, piroctone-olamine, zinc pyrithione, propylene glycol lotions, benzoyl peroxide, sodium sulfacetamide, and allylamine antifungals. Treatment with selenium sulfide may result in irritant dermatitis. Patients may require emollient or mild topical steroid application for a few days following therapy.
  • The topical azole antifungals work well, but combinations of compounds do not offer significantly different results. Topical azole and allylamine antifungals are applied every other night for 2 weeks. The weekly application of any of the topical agents for the following few months may help prevent recurrence. The main problem with the use of azole antifungals in tinea versicolor is the inconvenience of applying creams to a wide body surface area. The shampoo form of the antifungal can be used for extensive disease.
  • Selenium sulfide shampoo (eg, Selsun) is also a good prophylactic therapy when applied for a few minutes in the shower once or twice a month.
• Oral therapy
• • Some patients prefer oral therapy. In adolescents and adults, a single dose of oral ketoconazole (400 mg) is very effective. Having the patient take the ketoconazole with an acidic drink (eg, orange juice, cola) to improve absorption may enhance this therapy. The patient should wait an hour after ingestion and then exercise to the point of sweating. The patient then cools off, allowing the perspiration to dry on the skin, and showers after a few hours.
  • Oral therapy does not prevent the high recurrence rate, and treatment with oral ketoconazole may need to be repeated intermittently throughout the year. Oral itraconazole and fluconazole have also been proven effective but are rarely required. Some subgroups of M furfur are apparently not clinically responsive to oral terbinafine. Griseofulvin is not an effective therapy for tinea versicolor.
• Combination: Various regimens involve both topical and oral therapies. The most common is varying regimens of selenium sulfide shampoo or lotion and oral therapy with ketoconazole.

Activity

• Activity limitations are not necessary. However, active patients who excessively perspire are more likely to develop recurrences.

MEDICATION

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Tinea versicolor responds well to both topical and oral antimycotic therapies. Some patients prefer oral therapy because of convenience, while others prefer the safety of topical therapies. Many effective topical therapies are available without prescription and can be used for suppressive therapy or for treating recurrences without the need for a follow-up visit.

Topical therapy alone is indicated for most patients. Systemic treatment may be indicated for patients with extensive involvement, those with recurrent infections, or those in whom topical therapy has failed.

Drug Category: Topical selenium sulfide products

Selenium sulfide is effective at killing M furfur, the primary cause of tinea versicolor. These agents have cytostatic effects on the epidermis and follicular epithelium, thus reducing corneocyte production.

Drug Category: Antifungals, topical

Antifungal creams are effective at killing M furfur, the primary cause of tinea versicolor.

Drug Category: Antifungals, oral

These agents are effective at killing M furfur, the primary cause of tinea versicolor. The major exceptions are griseofulvin and terbinafine, which are not effective.

FOLLOW-UP

Section 8 of 11  

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• Medication
• Follow-up
• Miscellaneous
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Deterrence/Prevention

• Tinea versicolor has a high recurrence rate and may require frequent prophylactic treatment with intermittent topical or oral therapy.
• Good personal hygiene may help limit recurrences. Specifically, patients should shower as soon as possible after participating in activities or exercise that produce significant perspiration.

Prognosis

• Prognosis is excellent.
• Although tinea versicolor is recurrent in some patients, the condition remains very treatable.

Patient Education

• Tinea versicolor is caused by a fungus that is normally present on the skin surface and, therefore, is not considered a contagious disease.
• The disease causes no permanent sequelae, and any pigmentary alterations resolve entirely within a few months of adequate treatment.
• Effective therapy is available. Recurrences are common, and prophylactic therapy may be required.

MISCELLANEOUS

Section 9 of 11  

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Medical/Legal Pitfalls

• Routine evaluation of hepatic function before therapy is seldom warranted for young healthy patients. However, patients at extra risk for preexisting hepatic dysfunction need assessment before treatment. Hepatotoxicity has been associated with the use of ketoconazole tablets, including rare fatalities. The reported incidence of hepatotoxicity has been about 1 per 10,000 exposed patients. The median duration of ketoconazole therapy in patients who developed symptomatic hepatotoxicity was about 28 days, although the range extended to a low of 3 days. The hepatic injury is usually, but not always, reversible upon discontinuation of ketoconazole treatment. Several cases of hepatitis have been reported in children.
• In patients taking terfenadine concurrently with ketoconazole tablets, reports of torsades de pointes and other serious ventricular dysrhythmias (in rare cases, leading to fatality) have been recorded.
• Pharmacokinetic data indicate that oral ketoconazole inhibits the metabolism of astemizole, resulting in elevated plasma levels of astemizole and its active metabolite desmethylastemizole, which may prolong QT intervals.
• Ketoconazole may enhance the anticoagulant effect of coumarinlike drugs.

MULTIMEDIA

Section 10 of 11  

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Media file 1:  In patients with lighter skin color, lesions frequently are a light tan or salmon color.
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Media file 2:  Upon potassium hydroxide (KOH) examination, hyphae are visible and grow into strands within clumps of keratinocytes. Thick-walled spores frequently occur in grapelike clumps. Individual spores and short stubby hyphae float in the clear areas between clumps of keratinocytes. Many of the short hyphae are dystrophic.
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Media file 3:  Scale is frequently difficult to appreciate upon clinical examination.
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Media file 4:  This individual developed skin discoloration and mild itching every summer for the past few years. These patients should be instructed on the prophylactic use of topical therapy.
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Media file 5:  This superficial plaque of tinea versicolor is located in the right antecubital fossa of an adult. This appearance and distribution is uncommon but not rare. A potassium hydroxide (KOH) preparation confirmed the diagnosis.
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Media file 6:  Although tinea versicolor is uncommon in children in temperate climates, when it does occur, it is more likely to be atypical in distribution. This 7-year-old boy had areas of tinea versicolor across the forehead and both temples. He was in good health and lived in Washington state when he was diagnosed.
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Media file 7:  In some patients, the areas affected by tinea versicolor are not always obvious. In this patient, the abnormal areas are hypopigmented.
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Media file 8:  Clear adhesive tape can be pressed onto areas of tinea versicolor to collect hyphae and spores. The tape is then lightly pressed onto a glass slide, and a drop of methylene blue is placed at the edge of the tape. The methylene blue is allowed to run under the tape staining Malassezia furfur. The spores and hyphae easily are seen against a background clutter of keratinocytes and glue.
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Media file 9:  Some patients present with extensive tinea versicolor. This patient related that his discoloration had been present for more than 20 years. The light-colored areas on the abdomen are the normal areas of skin. Although topical therapy alone is usually effective, this patient may benefit from initial therapy with oral ketoconazole, followed by selenium sulfide applications in the shower 2-3 times a month.
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Media file 10:  Significant hyperpigmentation caused by a tinea versicolor infection.
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Media file 11:  Confluent and reticulated Gougerot and Carteaud papillomatosis.
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Media file 12:  Mycelium strands and numerous spores observed on a potassium hydroxide (KOH) preparation of tinea versicolor. This combination is commonly referred to as "spaghetti and meatballs."
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Media type:  Electron Microscopy

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
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• Follow-up
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• References

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Article Last Updated: Jan 16, 2007