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Tinea versicolor (pityriasis versicolor) is a common superficial fungal infection of the stratum corneum. Caused by the fungus Malassezia furfur, this chronically recurring disease is most prevalent in the tropics but is also common in temperate climates. Treatments are available and cure rates are high, although recurrences are common. Traditional topical agents such as selenium sulfide are effective, but recurrence following treatment with these agents is likely and often rapid. Currently, therapeutic interest is focused on synthetic "-azole" antifungal drugs, which interfere with the sterol metabolism of the infectious agent. Ketoconazole, an imidazole, has been used for years both orally and topically with great success, although it has not been approved by the Food and Drug Administration for the indication of tinea versicolor. Newer derivatives, such as fluconazole and itraconazole, have recently been introduced. Side effects associated with these triazoles tend to be minor and low in incidence. Except for ketoconazole, oral antifungals carry a low risk of hepatotoxicity.
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Pityriasis (tinea) versicolor, which consists of hyperpigmented and hypopigmented scaly patches, is often difficult to treat. A double-blind comparative study between once-a-day sodium sulfacetamide lotion and selenium sulfide lotion was undertaken. Both treatments were safe and efficacious. Selenium sulfide was statistically more efficacious (76.2% vs 47.8%, P=.013).
BACKGROUND: Tinea (pityriasis) versicolor is a superficial infection of the stratum corneum by the lipophilic fungus known as Malassezia furfur. OBJECTIVE: To evaluate the efficacy and safety of a 400 mg single dose or 7-day 200 mg daily dose of itraconazole capsules in the treatment of mycologically confirmed pityriasis versicolor. METHODS: A total of 50 patients were entered into a randomized, open, clinical trial comparing a 400 mg single dose (n = 24 for group 1) with a 7-day 200 mg daily dose (n = 26 for group 2) of itraconazole. Clinical signs and symptoms and mycologic evaluation (potassium hydroxide preparation and Wood's lamp) were performed before treatment, and at weeks 3 and 6 after treatment. RESULTS: Both regimens of itraconazole were effective. Our results showed that there were no significant differences in efficacy and safety between the two treatment regimens (chi-square tests, p > 0.05). CONCLUSIONS: On the basis of these findings, a single dose of itraconazole 400 mg/day was as effective as the 7-day 200 mg daily dose in the treatment of pityriasis versicolor.
BACKGROUND: The diagnosis of tinea versicolor can usually be made by clinical examination. Either potassium hydroxide (KOH) or Wood's light fluorescence are used to corroborate the diagnosis. Albert's solution has been reported as a method of visualizing dermatophytes. We compared Albert's solution to KOH in the diagnostic evaluation of tinea versicolor. METHODS: Twenty patients with clinical tinea versicolor were examined for the presence of hyphae and/or spores utilizing Albert's solution or KOH (20%) with dimethyl sulfoxide. RESULTS: All patients were positive for hyphae and/or spores by both methods. Preparations with Alberts' stains were faster and easier to read. CONCLUSIONS: Albert's solution is an alternate method to stain for fungal elements in patients with tinea versicolor.
BACKGROUND: Pityriasis (tinea) versicolor has a high tendency to recur after being treated successfully. Prophylactic treatment to reduce recurrence is needed. OBJECTIVE: To determine whether recurrence of pityriasis versicolor could be prevented by prophylactic itraconazole treatment. DESIGN: Open treatment followed by a randomized, double-blind, placebo-controlled phase. SETTING: Multinational outpatient centers. PATIENTS: A total of 239 consecutive patients were included; 238 started open treatment. A total of 209 patients started prophylactic treatment: 106 in the itraconazole group and 103 in the placebo group. INTERVENTIONS: Open treatment: itraconazole, 200 mg once daily for 7 days. Prophylactic treatment: itraconazole, 200 mg, or placebo twice daily 1 day per month for 6 consecutive months. MAIN OUTCOME MEASURES: Mycological cure rates at the end of open treatment and at the end of prophylactic treatment. RESULTS: Mycological cure at the end of open treatment was 92% (205/223). At the prophylactic treatment end point (6 months), mycological cure was 88% (90/102) in the itraconazole group and 57% (56/99) in the placebo group (P<.001). In open treatment, 11 patients were not able to be evaluated for efficacy. In prophylactic treatment, 4 patients in the itraconazole group and 4 in the placebo group were not able to be evaluated. Adverse events were reported during open treatment by 26 patients (11%) and during prophylactic treatment by 17 (16%) in the itraconazole group and 14 (14%) in the placebo group. No patients experienced any serious adverse events. CONCLUSIONS: Prophylactic itraconazole treatment is efficacious for pityriasis versicolor after 6 months, as is itraconazole in the treatment of pityriasis versicolor.
BACKGROUND: Tinea versicolor causes scaly macular lesions which vary in color from white to brown. In patients with dark skin, tinea versicolor is thought to have a tendency to be hypopigmented. This view has not been formally documented. OBJECTIVE: Our objective was to determine the pigmentary changes of lesions of tinea versicolor in patients with skin types IV and V. METHODS: One hundred cases of tinea versicolor in persons with skin types IV and V were studied. The pigmentary changes and their correlation with the age and sex of the patients and the duration, recurrence, site, and symptomatology of the lesions were determined. RESULTS: There was no correlation between the pigmentary variations of tinea versicolor and the type of skin, sex, and age of our patients or the duration, recurrence, site, and symptomatology of the lesions. CONCLUSIONS: In dark-skinned individuals, tinea versicolor does not tend to be significantly hypopigmented.
Tinea versicolor is a common noninvasive cutaneous fungal disease. We recount a case of tinea versicolor that mimicked type I (classic adult) pityriasis rubra pilaris. A 54-year-old white man reported a 20-year history of a recurrent pruritic eruption that had marginally improved with use of selenium sulfide shampoo and treatment with oral antihistamines. Results of a skin examination revealed erythematous plaques; islands of spared skin; and follicular erythematous keratotic papules on the trunk, shoulders, and upper arms. A lesion was scraped to obtain skin scales for potassium hydroxide staining. Examination of the stained samples revealed the characteristic "spaghetti and meatballs," confirming the diagnosis.
Pityrosporum orbiculare, the presumed etiologic agent of tinea versicolor, was cultured in vitro and antigenic extracts prepared from the cultured organisms. Studies with lymphocytes from human cord blood and peripheral blood of guinea pigs demonstrated that such extracts were not mitogenic. Further studies in guinea pigs indicated that the animals could be sensitized by the injection of P. orbiculare extract in Freund's complete adjuvant and that this extract could elicit lymphocyte transformation and delayed skin test responses in sensitized animals. A group of 12 tinea versicolor patients and 15 normal subjects were studied in vitro for cell-mediated immunity to P. orbiculare extract. The majority of the subjects tested in both groups demonstrated positive lymphocyte transformation responses to this extract, as well as to standard mitogens and common microbial antigens. However, lymphocytes from tinea versicolor patients produced significantly less leukocyte migration inhibitory factor activity when stimulated by Candida albicans and P. orbiculare extracts than did lymphocytes from normal subjects. This was also true if only subjects with positive lymphocyte transformation responses to these antigens were considered. Leukocyte migration inhibitory factor responses to streptokinase/streptodornase were not significantly different between the two groups. Therefore, it appears that although both normal subjects and tinea versicolor patients demonstrate prior sensitization to antigens of P. orbiculare, the effector function of lymphocytes from most tinea versicolor patients appears to be impaired in that they produce subnormal amounts of the mediator leukocyte migration inhibitory factor when stimulated with antigenic extracts of this organism.
Pityriasis (tinea) versicolor is a common disorder of adults. We cared for five infants (four males and one female) with the disease. Diagnosis was confirmed by potassium hydroxide preparation demonstrating the filaments of Malassezia furfur and/or Pityrosporum orbiculare, the yeast form. Three patients had lesions in the neonatal period. The mother of one baby had pityriasis versicolor. Two patients were siblings. One baby had associated atopic dermatitis and two had a positive family history of atopy.
Twenty patients with tinea versicolor were treated with propylene glycol 50% in water twice daily for 2 weeks. All of these were cured when seen 2 weeks after the last day of treatment. The patients found the treatment cosmetically attractive and only 2 patients complained of a slight burning sensation in the skin after application of the solution.
In patients with tinea versicolor, Pityrosporum orbiculare was cultured from tinea versicolor lesions in 100%, from normal-looking skin in 80%, and from apparently healed lesions in 69%. P. orbiculare was isolated from normal skin in 85% of patients with seborrheic dermatitis and in 90% of volunteers. The best substrate for isolation of P. orbiculare was a peptone-glucose-yeast extract medium containing glycerol monostearate and Tween 80, overlaid with olive oil. Germ tubes were produced when P. orbiculare was incubated in an atmosphere containing air with 7% CO2. Cultures of P. orbiculare and P. ovale did not show any fluorescence in Wood's light. The in vitro activity of miconazole, clotrimazole, econazole, sodium omadine, and sodium thiosulphate against P. orbiculare was found to correlate to the good clinical effect of these drugs in tinea versicolor. In addition several substances used as solvents or in vehicles had an inhibitory activity against P. orbiculare in vitro. Inoculation with P. orbiculare under plastic occlusion on the glabrous follicle-rich inside of the rabbit ear resulted in a tinea versicolor-like lesion after I week in 3 of 4 animals. One week after inoculation with P. orbiculare under plastic occlusion, experimental infections similar to those found clinically in tinea versicolor were seen in 10 of 12 patients with a history of tinea versicolor and in 3 of 6 normal volunteers. It was not possible to produce experimental infections without occlusion. Spontaneous healing usually occurred. In a retrospective study of 232 patients and prospective survey of 48 patients regarding susceptibility factors in tinea versicolor a higher (10.4%) than expected (3.8%) connection to seborrheic dermatitis was found.
Tinea versicolor is a common superficial fungal infection that typically affects young adults in warm, humid climates. We describe two young black children in the temperate northeastern Ohio area with tinea versicolor limited to the face. The occurrence of tinea versicolor on the face is unusual, as is its appearance before puberty. The mycologic and pathophysiologic characteristics of tinea versicolor infection are discussed, and several hypothesis are offered to explain the presence of tinea versicolor in these patients.
BACKGROUND: Tinea versicolor is a common superficial fungal infection caused by a lipophilic yeast. This chronically recurring opportunistic infection is especially prevalent in tropical and semitropical regions. The topical short-term application of ketoconazole 2% shampoo may provide effective and safe therapy for tinea versicolor. OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of a single application (1 day) versus three daily applications (3 days) of ketoconazole 2% shampoo versus placebo shampoo in the treatment of mycologically confirmed tinea versicolor. METHODS: Three hundred twelve patients were included in the primary analyses for this 31-day study. Global evaluation scores were measured on days 10 and 31 with a 5-point scale (1 = healed to 5 = worsening), and a cellophane tape test was done at baseline and days 3, 10, and 31. Efficacy was assessed by clinical response, defined as both a global evaluation score of 1 (healed) and a negative cellophane tape test on day 31. Signs and symptoms of tinea versicolor (scaling, itching, erythema, hypopigmentation, hyperpigmentation) also were evaluated at baseline, day 10, and day 31 with a 4-point scale (0 = absent to 3 = severe). RESULTS: Both regimens of ketoconazole shampoo were significantly (P < .001) more effective than placebo for rate of clinical response, global evaluation scores, and mycologic outcomes (cellophane tape test). The clinical response rates at day 31 were 73%, 69%, and 5% for the 3-day ketoconazole, 1-day ketoconazole, and placebo groups, respectively. The difference in the efficacy of the two ketoconazole treatment regimens was not statistically significant. There were no significant differences between any of the treatment groups in the number of patients who experienced adverse events. No serious adverse events occurred and no patient withdrew from the trial prematurely because of an adverse event. CONCLUSION: Ketoconazole 2% shampoo, used as a single application or daily for 3 days, is safe and highly effective in the treatment of tinea versicolor.
Lymphocyte transformation responses to Pityrosporum orbiculare were compared in tinea versicolor patients and normal subjects with respect to the number of antigen responsive cells (ARC) present, the first generation lymphocyte response (FGLR), and the magnitude of the total response. A modest, but statistically significant decrease in the magnitude of the lymphocyte transformation response to P. orbiculare was found in the tinea versicolor group and appeared to be accounted for by a similar decrease in the number of ARC to the organism in this group. There did not appear to be any significant rearrangements in the later phases of the lymphocyte transformation response in the tinea versicolor group. Significant enhancement of the response was not obtained using indomethacin, cimetidine or removal of adherent cells. Therefore, in spite of long standing contact wih P. orbiculare and evidence from previous studies of elevated antibody titres against it, patients with tinea versicolor appear to have diminished lymphocyte transformation responses to this organism, apparently due to decreased numbers of cells that are initially responsive to its antigens.
Sera from patients with tinea versicolor and controls of various ages were investigated with the indirect immunofluorescence technique for antibodies against Pityrosporum orbiculare, the etiologic agent of tinea versicolor. No differences in titers were observed between patients and adult controls. Also, there were no differences in antibody titers in the patient group with regard to age and sex, or to duration and distribution of lesions. A statistically significant difference in antibody titers was observed between adult controls and children, particularly the youngest. Antibodies against Candida albicans from randomly selected sera from the same groups showed the same tendency, although only statistically significant when children of 5 years or younger were compared with adult controls. This investigation indicates that although P. orbiculare is capable of inducing antibodies, these are not correlated to tinea versicolor but occur when an individual becomes colonized with the organism.
Hyperpigmentation in lesions of tinea versicolor has previously been reported to be a result of the effects of the fungus Pityrosporon orbiculare on melanosome formation and distribution. Examination of biopsy specimens from lesions of hyperpigmented tinea versicolor involving vitiliginous skin reveals an absence of melanosomes and melanocytes. Reddish-tan and fawn-colored hyperpigmentation in tinea versicolor of this type is not due to melanin pigment. The possible nature of the pigmentation that delineates hyperpigmented tinea versicolor from normal skin is discussed.