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Pityriasis versicolor
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Exam Tips
- In OSCEs, score marks by explicitly stating: non-contagious, recurrent, and pigment recovery is slower than fungal clearance.
- Distribution + fine scale is high-yield: sebum-rich trunk/upper arms/neck with subtle branny scale strongly supports diagnosis.
- Wood's lamp can help but is not definitive; some lesions do not fluoresce.
- After treatment failure, first check adherence and whether residual dyspigmentation is post-inflammatory/post-infective rather than active disease.
- If hypopigmented lesions in darker skin, always discuss key differentials (especially vitiligo and pityriasis alba) and how scale/distribution help distinguish them.
Definition
Pityriasis versicolor (tinea versicolor) is a common, superficial fungal disorder in which Malassezia yeasts overgrow within the stratum corneum, producing multiple variably coloured macules with fine scale. It is not a hygiene-related or contagious condition, but a recurrent dysbiosis of normal skin flora, especially on sebaceous areas such as the upper trunk, neck, and proximal upper limbs.
Pathophysiology
Malassezia species (most often M. globosa, also M. sympodialis and M. furfur) are part of normal cutaneous flora but can shift from a commensal yeast form to a pathogenic mycelial form under favourable conditions (heat, humidity, sweating, occlusion, altered immunity). These obligate lipophilic yeasts thrive in sebum-rich skin, causing superficial stratum-corneum infection and subtle inflammation with fine branny scale. Pigment change is multifactorial: reduced melanogenesis (including tyrosinase inhibition by fungal metabolites) can cause hypopigmentation, while mild inflammation can produce hyperpigmentation, so lesions may appear white, pink, fawn, red, brown, or black depending on skin type and tanning state.
Risk Factors
- Warm, humid climate or summer months; recent travel to tropical climates
- Hyperhidrosis (excess sweating)
- Occlusive oily creams/lotions on skin
- Adolescence/young adulthood (higher sebaceous activity, peak in early 20s)
- Immunodeficiency (for example diabetes mellitus, Cushing syndrome)
- Immunosuppression (including systemic corticosteroids or other immunosuppressants)
- Malnutrition
- Oral contraceptive use
Clinical Features
Symptoms
- Often asymptomatic
- Mild pruritus may occur
- Cosmetic concern due to patchy dyspigmentation, often more obvious after sun exposure
Signs
- Multiple round/oval macules that may coalesce into larger patches
- Fine powdery/branny scale (can be subtle)
- Variable colour: white, pink, fawn, red, brown, black; hypopigmentation may predominate in darker skin
- Typical distribution on sebum-rich areas: upper trunk, shoulders/upper arms, neck, abdomen; can involve axillae, groin, face, scalp, thighs, genital skin
- Wood's lamp may show gold-yellow, yellow-green, or coppery-orange fluorescence (not universal)
- See image reference: compare Wood's lamp fluorescence patterns and trunk distribution photographs in a dermatology atlas/text chapter on superficial fungal infection
Investigations
Clinical diagnosis:Characteristic variably pigmented, finely scaling macules/patches on sebaceous skin; usually sufficient for diagnosis
Wood's lamp examination:Possible bright gold-yellow/yellow-green/coppery-orange fluorescence; absence of fluorescence does not exclude diagnosis
Skin scrapings for mycology (if uncertain diagnosis or treatment failure):Supports superficial Malassezia infection; used selectively rather than routinely
Management
Lifestyle Modifications
- Explain that condition is not contagious and not due to poor hygiene
- Set expectations: antifungal treatment clears infection faster than pigmentation; repigmentation may take weeks to months (sometimes longer)
- Address recurrence risk and advise early self-recognition/re-treatment of new episodes
- Consider prophylaxis before predictable triggers (hot/humid travel, significant sun exposure) in frequent relapsers
Pharmacological Treatment
Topical imidazole shampoo (first-line for extensive disease)
- Ketoconazole 2% shampoo: age 12 years and over, apply to whole affected body once daily for up to 5 days, leave on skin up to 15 minutes then rinse
- Ketoconazole 2% shampoo prophylaxis (age 12 years and over): once daily for up to 3 days before intense sun/hot-humid exposure
- Ketoconazole 2% shampoo maintenance in recurrent cases: whole-body application every 1-4 weeks
Not licensed under 12 years. Useful when large surface area is affected.
Topical antifungal creams (small/localized areas)
- Clotrimazole cream: apply twice daily for 2-3 weeks
- Econazole cream: apply twice daily for 2-3 weeks
- Ketoconazole cream: apply twice daily for 2-3 weeks
- Terbinafine cream: apply twice daily for 2-3 weeks
Clotrimazole is generally preferred topical option in pregnancy. Reassess adherence and diagnosis if response is poor.
Oral triazoles (consider if topical failure or very widespread disease, adults not pregnant)
- Itraconazole 200 mg once daily (specialist/BNF regimen-dependent)
- Fluconazole (BNF regimen-dependent)
Avoid oral azoles in pregnancy. Check interactions and hepatotoxicity risk (notably CYP-mediated interactions with itraconazole/fluconazole); use only when clearly indicated.
Complications
- Frequent relapse (common; can be very high within 2 years in some settings)
- Persistent post-infective dyspigmentation despite mycological cure
- Psychosocial distress or reduced confidence due to visible skin colour change
- Misdiagnosis leading to unnecessary treatment of other dermatoses
Prognosis
Overall prognosis is good with appropriate antifungal treatment, and mycological clearance is usually achieved quickly. However, the disorder behaves chronically with common recurrence, particularly in warm/humid conditions, and pigment normalization often lags behind clinical clearance by weeks to months.
Sources & References
🏥BMJ Best Practice(2)
💊BNF Drug References(5)
- Fluconazole[management.pharmacological]
- Itraconazole[management.pharmacological]
- Ketoconazole[management.pharmacological]
- Selenium[management.pharmacological]
- Terbinafine[management.pharmacological]
✅NICE Guidelines(1)
- Pityriasis versicolor[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1629, 1630)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1650)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1682, 1683)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1544)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1649, 1650)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1682, 1683)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1599, 1600)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1600)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1629)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1543, 1544)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 146)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 167, 168)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 167, 168)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 146)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 899, 900)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 422, 423)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 423)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 424)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 423)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 423, 424)[context]