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Tinea Versicolor

Pityriasis Versicolor

Tinea versicolor is a cutaneous fungal infection which is most common in tropical and subtropical regions of the world.


Presentation

Typically, tinea versicolor presents with well defined, variably sized hypopigmented macules and patches covered with fine white scales which are hardly visible to the naked eye. The scales can be made more evident by scraping the affected lesions with a sharp object. Hyperpigmented patches can also occur.

These lesions mainly occur on the neck, axillae, chest, back and proximal extremities are affected. Rarely, face and inframammary folds of females are affected.

Lesions maybe variously coloured ranging from reddish brown, dark brown to blackish. These lesions are usually asymptomatic. Pruritus may be present on the affected areas. The lesions appear hypopigmented in dark skin and hyper pigmented in lighter skin.

Plethora
  • Given the lack of a standard method for Malassezia susceptibility testing and the plethora of published methods, we also developed an improved method for this genus.[ncbi.nlm.nih.gov]
Hyperpigmentation
  • 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.[ncbi.nlm.nih.gov]
  • Disorders of hyperpigmentation. In: Bolognia JL, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Philadelphia, PA: Elsevier; 2018:chap 67. Patterson JW. Mycoses and algal infections. In: Patterson JW, ed. Weedon's Skin Pathology. 4th ed.[nlm.nih.gov]
  • African Americans may have a loss of skin color (hypopigmentation) or an increase in skin color (hyperpigmentation). www.nlm.nih.gov/medlineplus[voxhealth.co]
  • References: [4] [5] Clinical features Round, well-demarcated macules that reveal a fine, subtle scale with gentle scraping can coalesce into patches (which may have irregular shapes) Colors vary from hypopigmentation, pityriasis versicolor alba, to hyperpigmentation[amboss.com]
Hypopigmented Macule
  • Presented in this report is a 34-year-old man with an interesting case of folliculocentric tinea versicolor manifesting as perifollicular hypopigmented macules on the lower back.[ncbi.nlm.nih.gov]
  • Out of 200 patients, itching was an associated complaint in 44 (22%) patients (39 with hypopigmented macules and 5 with hyperpigmented macules).[doi.org]
Hypopigmented Macule
  • Presented in this report is a 34-year-old man with an interesting case of folliculocentric tinea versicolor manifesting as perifollicular hypopigmented macules on the lower back.[ncbi.nlm.nih.gov]
  • Out of 200 patients, itching was an associated complaint in 44 (22%) patients (39 with hypopigmented macules and 5 with hyperpigmented macules).[doi.org]
Eruptions
  • A most unusual case of tinea versicolor is presented in which the eruption was localized only to the patient's flexural areas.[ncbi.nlm.nih.gov]
  • The colour of the eruption may appear lighter or darker than the surrounding normal skin, hence the name “versicolor”. The rash itself may be slightly raised with a fine scale.[dermcoll.edu.au]
  • Called also pityriasis versicolor. tin·e·a ver·sic·'o·lor an eruption of tan or brown branny patches on the skin of the trunk, often appearing white, in contrast with hyperpigmented skin after exposure to the summer sun; caused by growth of the fungus[medical-dictionary.thefreedictionary.com]
  • Tinea versicolor is a condition characterized by a skin eruption on the trunk and proximal extremities.[en.wikipedia.org]
Eczema
  • The following conditions are sometimes indistinguishable from tinea versicolor on simple inspection: Pityriasis alba: This is a mild form of eczema (seen in young people) that produces mild, patchy lightening of the face, shoulders, or torso.[medicinenet.com]
  • 145 Glossary 161 Formula Index 175 Drept de autor Termeni și expresii frecvente Pasaje populare Pagina 156 - Clears heat and facilitates astringency, stops itching and disperses inflammation in the treatment of dermatitis due to chemical (allergy), eczema[books.google.ro]
  • Dermatologists don’t know exactly what causes eczema, but the condition is being diagnosed more frequently than in the past. It can be associated with allergies, asthma, and a family history of eczema.[dermrochester.com]
  • These are, for the most part, the ones that are recommended for other skin diseases such as eczema and acne.[emedicinehealth.com]
Impulsivity
  • After you find out that your strange skin condition is caused by a fungus, your first impulse may be to take a long, hot shower and scrub the fungus off of your skin.[web.archive.org]
Incontinence
  • A LM examination showed epidermal colonization with pityrosporum hyphae and spores accompanied by variable epidermal and dermal atrophy characterized by rete-ridge effacement, subepidermal fibroplasia, pigment incontinence and elastolysis.[ncbi.nlm.nih.gov]

Workup

Tinea versicolor is easily diagnosed by simple clinical examination. The macules and patches of tinea versicolor are very characteristic and should be differentiated from other skin conditions which mimic this condition.

Physicians can elicit the ‘scratch sign’ or ‘Besnier sign’ which normally accentuates the fine white scales when the affected area is scratched with a pointed object.

When examined with a Wood’s lamp, scales fluoresce golden yellow to green. Microscopic examination of the lesions show typical ‘spaghetti and meatballs’ appearance due to presence of both hyphae and spores of the yeast [7].

No laboratory tests are required for this condition.

Malassezia Furfur
  • Malassezia furfur in skin scale from a patient with tinea versicolor PHIL 3938 lores.jpg 700 470; 22 KB Malassezia spores 2.jpg 2.490 1.128; 1.007 KB Malassezia spores.jpg 3.726 1.142; 1,68 MB P versicolorklein.jpg 1.272 954; 532 KB Photographic atlas[commons.wikimedia.org]
  • Ciclopirox (Ciclopirox olamine) is an alternative treatment to ketoconazole, as it suppresses growth of the yeast Malassezia furfur.[en.wikipedia.org]
  • , versicolor; tinea, Infection by Malassezia furfur, Infection by Pityrosporum furfur, pityriasis versicolor Italian Tinea versicolor, Pityriasis versicolor, Pitiriasi versicolor, Tigna versicolor Dutch pityriasis versicolor, Malassezia furfur; infectie[fpnotebook.com]
Lymphocytic Infiltrate
  • There will be slight perivascular inflammation and lymphocytic infiltrate may be present. Hyperkeratosis and acanthosis may be present in the epidermis. Microorganisms are only seen in the stratum corneum, no other layers of skin are affected.[symptoma.com]

Treatment

The treatment usually consists of topical antifungal creams mainly consisting of selenium sulphide (2%), as well as azoles and other antifungals [8]. Application to the affected area and surrounding skin should be done twice or once a day for 2 weeks. Other topical applications include clotrimazole, miconazole, and terbinafine can also reduce the patches. Antifungal shampoos can also be applied to the body.

Oral antifungals are given; mainly fluconazole and ketoconazole. These are preferred as they are more convenient and simpler. Oral antifungals like ketoconazole 200mg are given once a day for 10 days; they are better reserved for persistence or recurrence [9].
Nowadays, a combination of oral and topical antifungals is given for better results.

Pigmentary changes take about 1-2 months to resolve after antifungal therapy is started; however, fungal activity completely stops by 2 weeks of treatment.

Patient has to be reassured that skin colour will return to normal after a couple of months. The skin colour eventually darkens after sun exposure. Occasionally, pale white marks may remain permanent for unknown reasons.

Prophylactic treatment is given intermittently in the form of oral antifungals, given once a month to reduce the chronicity of this infection.

Prognosis

With treatment this fungal infection has a very good prognosis. Even though pigmentation takes time to disappear may be even months, the fungal activity is controlled within two weeks. So even though hypopigmentation does not go away fast, patient is disease free.

Reappearance of tinea versicolor is very common especially in the hot season thus, making tinea versicolor a chronic skin infection. Intermediate preventive care can prevent the relapse.

Etiology

Tinea versicolor is said to be caused by an overgrowth and over activity of a fungus which belongs to the genus Malassezia [1]. There are two forms: Malassezia globosa and Malassezia furfur. The saprophytic fungi are a normal part of the skin flora. They inhabit the sebaceous ducts and follicular infundibulum as these are lipophilic microorganisms [2]. As a result these lesions are mainly seen in seborrheic regions of young individuals, as sebaceous glands are most active during adolescence.

Moist and humid conditions along with excessive sweating tend to cause and over activity of these normal saprophytes. Hormonal imbalance along with weakened immune system [3] also seems to play a role in the etiology but the exact mechanism is not clearly understood.

Since this yeast is lipophilic, hyperhidrosis and overactive sebaceous glands are important predisposing factors.

Epidemiology

Tinea versicolor is one of the most commonly occurring skin infections which affect young individuals. There is equal incidence among men and women.

It affects all races but more visibly evident in dark skinned individuals. It rarely affects elderly people and occurs more in tropical or subtropical countries.

Sometimes this condition may not even be visible to the individual as a result patient may not even take treatment. The exact prevalence is not known as it is not a reportable infection.

Seborrheic dermatitis and acne vulgaris have common associations with tinea versicolor.

Sex distribution
Age distribution

Pathophysiology

Irregular pigmentation is the main pathology [4] in this condition, which occurs due to increased production of a normal inhabiting yeast Malassezia furfur or Malassezia globosa. They are typically lipophilic and saprophytic in nature.

The change of the fungus from saprophyte to parasitic is the main underlying pathology. The predisposing factors for this change are moist humid conditions, hyperhidrosis, excessive sebum production and other various factors. As a result of this, these microorganisms release azelaic acid which is known to inhibit tyrosinase activity, which is responsible for melanin production as a result hypopigmentation occurs [5].

The exact mechanism of hyperpigmentation is not known but is assumed to be because of large malanosomes.

Microscopically, scrapings from the lesions will show short, broad, septate hyphae and clusters of round spores that look like ‘spaghetti and meatballs’. There will be slight perivascular inflammation and lymphocytic infiltrate may be present. Hyperkeratosis and acanthosis may be present in the epidermis. Microorganisms are only seen in the stratum corneum, no other layers of skin are affected [6].

Prevention

As the fungus is present normally in all individuals there is no accepted prevention. Prevention mainly will be to prevent recurrence.

Excessive sweating, sun exposure and moist humid climate should be avoided. Oral antifungals are given intermittently once or twice a month to prevent the reappearance.

Medications for prevention are mainly selenium sulphide shampoo, ketoconazole cream, shampoo or tablets. Itraconazole is mainly given as oral preventive therapy [10].

Summary

Tinea versicolor is a common cutaneous fungal infection, which results in hypopigmented or hyperpigmented patches on the skin. It is one of the most common fungal infections affecting the skin. The yeast responsible for this belongs to the genus Malassezia, [1] which is a normal inhabitant of the skin.

This fungal infection can be chronic in nature especially in predisposed individuals. It occurs mainly on the trunk and extremities. Hot humid weather and excessive sweating are important predisposing factors, thus it is more common in tropical regions. It is not a contagious disease.

This condition has nothing to do with other tinea conditions (ringworm) that are caused by dermatophytes. Tinea versicolor is restricted till stratum corneum and does not penetrate deeper layers.

Versicolor means variously coloured, as in this skin infection, there are various skin patches of different colours in comparison to the surrounding skin.

Though the treatment for tinea versicolor is very effective, it tends to reappear often. The recurrence is mainly in the hot season as a result this condition becomes chronic.

Patient Information

Tinea versicolor is a common fungal infection that causes patches on the skin which are either lighter or darker than the surrounding skin. This fungus is normally present on the skin in healthy individuals, but when it grows out of control the skin infection arises. The exact mechanism of formation of these patches is not known, but the fungus is the main causative agent.

This mainly affects the chest, back, neck and underarms and usually affects young adults. Excessive sweating, moist humid climate and oil secretion are important factors to promote overgrowth of this fungus.

Symptoms mainly include discoloured patches son the skin which maybe either lighter or darker than the surrounding skin. Mild itching may be present on affected areas.

This condition can be treated with over the counter antifungal creams but it is best to consult a physician. The physician will clinically examine the affected area or may ask for microscopic examination of the skin scrapings from affected lesion if the diagnosis is unclear.

Treatment mainly consists of antifungal creams which need to be applied daily for a minimum two weeks for effectiveness. Oral antifungals will also be given in combination with cream. Once treatment is started the fungal activity stops by two weeks but discoloured patches may take time to return to normal colouration. There is a high tendency for this condition to reoccur. Preventive treatment is given on and off especially during the hot season.

This condition is not contagious and with proper treatment and preventive measures, tinea versicolor can be bought under control.

References

Article

  1. Crespo-Erchiga V, Florencio VD. Malassezia yeasts and pityriasis versicolor. Curr Opin Infect Dis. 2006 Apr;19(2):139-47.
  2. Morishita N, Sei Y, Sugita T. Molecular analysis of malasseziamicroflora from patients with pityriasis versicolor. Mycopathologia. 2006 Feb;161(2):61-5.
  3. Burkhart CG, Dvorak N, Stockard H. An unusual case of tinea versicolor in an immunosuppressed patient. Cutis. 1981;27(1):56-8.
  4. Mendez-Tovar LJ. Pathogenesis of dermatophytosis and tineaversicolor. Clin Dermatol. 2010 Mar 4;28(2):185-89.
  5. Gaitanis G, Velegraki A, Alexopoulos EC, Chasapi V, et al. Distribution of Malassezia species in pityriasis versicolor and seborrhoeic dermatitis in Greece. Typing of the major pityriasis versicolor isolate M. globosa. Br J Dermatol. 2006 May;154(5):854-9.
  6. Suwattee P, Cham PM, Solomon RK, Kaye VN. Tinea versicolor with interface dermatitis. J Cutan Pathol. 2009 Feb;36(2):285-6.
  7. Lim SL, Lim CS. New contrast stain for the rapid diagnosis of pityriasis versicolor. Arch Dermatol. 2008 Aug;144(8):1058-9.
  8. Gupta AK, Lyons DC. Pityriasis versicolor: an update on pharmacological treatment options. Expert Opin Pharmacother. 2014 Aug;15(12):1707-13.
  9. Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg. 2014 Mar-Apr;18(2):79-90.
  10. Faergemann J, Gupta AK, Al Mofadi A, Abanami A, et al. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol. 2002 Jan;138(1):69-73.

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Last updated: 2019-07-11 21:42