Pityriasis versicolor

What is pityriasis versicolor?

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The differential diagnoses include seborrhoeic dermatitis, psoriasis, tinea corporis, vitiligo if pale on tanned skin and if a large solitary patch, consider early T cell lymphoma of the skin.

Pityriasis versicolor is a common skin complaint in which flaky discoloured patches appear mainly on the chest and back. The term pityriasis is used to describe skin conditions in which the scale appears similar to bran. The multiple colours arising in the disorder give rise to the second part of the name, versicolor. It sometimes called tinea versicolor, although the term tinea should strictly refer to infection with a dermatophyte fungus.

Clinical features
Pityriasis versicolor affects the trunk, neck, and/or arms, and is uncommon on other parts of the body. The patches may be pink, coppery brown or paler than surrounding skin. They may be mildly itchy. Pale patches may be more common in darker skin; this appearance is known as pityriasis versicolor alba and is less likely to itch. Sometimes the patches start scaly and brown, and then resolve through a non-scaly and white stage. A yellow-green fluorescence may be observed on examination of affected areas with a Wood's light (long wave ultraviolet A). Pityriasis versicolor is more common in hot, humid climates or in those who sweat heavily, so it may recur each summer. Pityriasis versicolor does not appear to predispose affected areas to sunburn even when it causes pale white marks.

Pityriasis versicolor

More images of pityriasis versicolor ...

What is the cause of pityriasis versicolor?

Malassezia, which may also be found on normal skin. Usually Malassezia species grow sparsely in the seborrhoeic areas (scalp, face and chest) without causing a rash. In some individuals they grow more actively on the skin surface, for unknown reasons. It is easier to demonstrate the yeasts in scrapings taken from the brown type of pityriasis versicolor than from the white type. Microscopy is reported as positive if hyphae and yeast cells are seen; they resemble spaghetti and meatballs. However, cult ure is often negative because it is quite difficult to persuade the yeasts to grow in a laboratory. It is only recently that nine different species of Malassezia have been identified. The most common species of yeast cultured from pityriasis versicolor patches are M globosa and M sympodialis. The pale type of pityriasis versicolor is thought to be due to a chemical produced by Malassezia that diffuses down and impairs the function of the pigment cells in the underlying skin.

Malassezia furfur under the microscope

Treatment
Topical and oral antifungal agents are used to treat active pityriasis versicolor. These may include:

Propylene glycol Sodium thiosulphate solution Selenium sulfide Topical azoles including clotrimazole, miconazole, econazole and ketoconazole in various formulations Terbinafine gel Ciclopirox cream/solution

Apply the medicine widely over the affected areas before bedtime for as long as directed (usually about two weeks). Patients with extensive or persistent pityriasis versicolor may be prescribed ketoconazole tablets or itraconazole capsules for a few days. As few as two tablets will clear many cases for several months. Vigorous exercise an hour later may help the medication to work as it comes out in the sweat. Do not shower for a few hours.

Recurrences
Pink or brown types of pityriasis versicolor generally clear satisfactorily with treatment but the rash often recurs when conditions are right for theMalassezia to proliferate. The antifungal treatment should be repeated when the scaly component of pityriasis versicolor recurs. Oral antifungal treatment may be prescribed for one to three days each month as a preventative in those who have frequent recurrences.

The pale type of pityriasis versicolor also generally clears up with treatment and the skin eventually tans normally with sun exposure. However, occasionally white marks are permanent for unknown reasons, persisting long after the scaling and yeasts have gone and despite exposure to the sun. In such cases antifungal treatment may be unhelpful.

Tinea versicolor is a very common yeast infection of the skin particularly seen in moist tropical climates. A small saprophytic fungus that we all have on the body surface, Malassezia furfur, grows as a pink slightly scaly rash which may present as a white area because it inhibits normal pigmentation after sun exposure. Management of the condition is discussed at the following reference. Note that Griseofulvin does not work on yeasts. It only works

The differential diagnoses include seborrhoeic dermatitis, psoriasis, tinea corporis, vitiligo if pale on tanned skin and if a large solitary patch, consider early T cell lymphoma of the skin. on dermatophytes so it is of no value in this type of fungus infection. Tinea versicolor is a yeast infection of the skin due to Malassezia furfur. We all have this yeast as part of our normal body flora but in some people, for reasons we do not understand, the yeast proliferates on the skin surface and becomes a cosmetic problem. People with the rash are often unaware they have it. On white skin the pale pink, slightly scaly lesions can be hardly visible and are usually asymptomatic .ie they do not itch. However they interfere with normal skin pigmentation so that in tanned skin, involved areas do not tan and stand out as pale, white, slightly scaly patches, mainly on the upper back and shoulders. The scale may only become apparent by scraping with your fingern ail or a surgical blade. A Woods light is useful to highlight the involved areas of the skin. It is difficult to culture this yeast but examination of skin scrapings treated with KOH will show clusters of fungal budding cells and hyphae colloquially known as spaghetti and meatballs! Treatments include several antifungal topicals such as Selsun shampoo containing selenium sulphide applied for 10 mins across the involved areas of skin and washed off or one of the miconazole creams such as Nizoral used twice daily for two weeks. Pevaryl foaming solution , another azole compound , applied as a wash and left on overnight to be washed off the next morning, can be effective treatment for a spell if used for three consecutive nights. Oral anti fungals such as Griseofulvin do not work in this condition but Ketoconazole (Nizoral) orally is very effective at 200mgs daily for 10 days and then 200mgs weekly for 10 weeks to try to stop the yeast regrowing. It is usually used in those patients with severe involvement who have failed topical therapy. Remember though that the white areas when treated will not repigment until the person has significant sun exposure to stimulate the melanocytes. Generally speaking there are few reasons to refer this condition for a Special ists opinion. Severe involvement can be a marker for the AIDS complex. The yeast Malssezia furfur sometimes proliferates mainly in hair follicles on the upper back and chest. There it gives rise to papules and pustules and is known as Pityrosporum folliculitis. The condition is sometimes quite itchy. It superficially looks like acne vulgaris but there are no comedones. A swab for culture will fail to grow bacteria. Some patients have associated typical tinea versicolor but not all and seborrhoeic dermatitis is also more

commonly seen. Pityrosporum folliculitis is difficult to diagnose but should be considered if empirical use of tetracycline antibiotics for presumed acne vulgaris has not been successful. The best therapy is oral ketoconazole 200mgs daily for one month to adequately reduce yeast numbers in the follicles. Despite prolonged systemic therapy like this recurrences of the condition are often seen.