Pityriasis Versicolor

Pityriasis versicolor is a fungal infection of keratinized skin produced by several different kinds of Malassezia species (55). Also known by the misnomer, tinea

Table 16 Tinea Cruris

Diagnosis Symptoms Clinical appearance Differential diagnosis

Therapy

Tinea cruris Pruritus

Red, well-demarcated scaling plaques with accentuation of peripheral scale on proximal, medial thighs

Psoriasis, lichen simplex chronicus/ eczema, candidiasis, erythrasma

Any topical azole cream or terbinafine. If fungal folli-culitis is present, oral griseofulvin, fluconazole, itraconazole, terbinifine versicolor, this is not a dermatophytosis, but rather an infection of yeast forms. Like tinea cruris, this is an infection much more common in men than in women.

Generally, pityriasis versicolor is asymptomatic. An occasional patient describes itching. Morphologically, this infection is characterized by almost macular, coalescing papules that exhibit very subtle and fine scale on close examination (Fig. 21). These papules can be pink, tan, or hypopigmented, hence the term "versicolor." Pityriasis versicolor most often begins on the upper, central back and chest, and papules coalesce into larger plaques and then extend preferably to the proximal arms. Very occasionally, scattered papules extend as far as the lower abdomen and mons.

The differential diagnosis includes dermatoses with papulosquamous morphology. These include, primarily, secondary syphilis, tinea corporis, pityriasis rosea, and guttate psoriasis. The diagnosis is made by the identification of typical pityriasis versicolor on the trunk and confirmed by direct microscopic visualization of the hyphae/pseudohyphae and budding yeast within the stratum corneum of skin scrapings.

Treatment consists of either topical azoles as used for tinea cruris or a very short course of an oral azole such as ketoconazole 400 mg per week for two doses

Tinea Versicolor Labia
Figure 21 (See color insert) Pityriasis versicolor is characterized by hypopigmented, pink, or tan (as seen here) well-demarcated flat papules with very subtle scale.
Table 17 Pityriasis Versicolor

Clinical

Differential

Diagnosis

Symptoms

appearance

diagnosis

Therapy

Pityriasis

Usually none;

Pink, brown, or

Pityriasis rosea,

Any topical azole

versicolor

occasional

hypopigmen-

secondary

cream applied

mild irritation

ted, well-

syphilis,

one to two

or pruritus

demarcated,

guttate

times a day

lightly scaling

psoriasis, tinea

until clear; if

2-10 mm

corporis/cruris

extensive,

papules

ketoconazole

coalescing into

100mg/day

larger plaques

for 5 days

centrally at

or fluconazole

times

300mg/wk for 2 weeks

or fluconazole 300mg twice, one week apart (56,57). Itraconazole given orally as a one-time dose of 400 or 200 mg a day for a week is effective as well (58). Selenium sulfide shampoos and lotions are frequently irritating and annoying in the anogenital area and generally should be avoided.

Pityriasis versicolor is frequently a recurrent condition, and patient should be advised that retreatment may be necessary in the future. Some patients benefit from once or twice monthly application of an azole cream to prevent recurrence. Oral itra-conazole given intermittently has also been shown efficacious for the prevention of recurrent pityriasis versicolor (Table 17) (59).

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