MILITARY MEDICINE, 178, 8:904, 2013

Pityriasis Versicolor: Avoiding Pitfalls in Disease

Diagnosis and Therapy
LT Shayna C. Rivard, MC USN
ABSTRACT Pityriasis versicolor is common among young active duty members with overactive sweat glands
working in humid environments and results in pigmentary changes that can be profound in those with darker skin. This
article addresses several issues related to making the correct diagnosis and providing appropriate treatment, as well as
the specific challenges military providers may face in these cases.

INTRODUCTION
The following case of pityriasis versicolor exemplifies the
importance of ruling out similar dermatologic conditions,
selecting an optimal treatment plan, and taking into account
special considerations military providers face. A 21-year-old,
otherwise healthy, active duty Marine Corps man was seen
in clinic for hypopigmented lesions on his back and neck,
initially appearing in 2009. Despite initiating a trial of overthe-counter topical terbinafine in 2011, his symptoms persisted
and became more bothersome by January 2012. The patient
was evaluated in the same clinic in July 2012, diagnosed with
tinea corporis, and prescribed 250 mg oral terbinafine daily for
30 days by a provider who moved soon after. Three months
later, the patient was seen with hypopigmented macules and
patches with very thin scaling when scraped (Fig. 1). The patient
was diagnosed with tinea versicolor (pityriasis versicolor1) and
prescribed 2% ketoconazole shampoo with instructions to use
the shampoo once daily for 3 consecutive days and follow up.
Upon re-evaluation, the patient reported no change, but on
examination the lesions did not show scale, suggesting a cure.
The patient was followed after a few months of continued
ketoconazole treatment. He reported an overall decrease in pruritic symptoms and was counseled that the hypopigmentation
might remain for several months.
To make the correct diagnosis of pityriasis versicolor, it is
important to distinguish between two other dermatologic
conditions: tinea corporis and pityriasis rosea.1 These three
conditions must be differentiated as they require different
treatments. Of note, additional differential diagnoses including vitiligo should be considered1,2; however, only the three
aforementioned diagnoses will be discussed further.
Pityriasis versicolor is a disease process that occurs when the
yeast, Malassezia (a component of normal skin flora), changes
to its hyphal form and causes pigmentary changes.2Keratinase
is also produced and causes loosening of the stratum corneum
and subsequent scale formation.3,4 The disease may present as
either hypopigmentation or hyperpigmentation. If tension is

Combat Logistics Regiment 17, Box 555607, Building 140199, Camp

Pendleton, CA 92055.
doi: 10.7205/MILMED-D-13-00057

904

placed on skin lesions, a wrinkling of the skin with visible scale

may be evident. Scraping the area with a sharp blade or glass
slide may reveal a powder or scale attributable to the effect
of keratinase.2,3,5 This observation can be especially useful
in austere environments without the ability to perform more
definitive testing.3 Woods lamp will also show a white to soft
yellow glow.1,2,6 The gold standard for diagnosis is a KOH
prep, which reveals a spaghetti and meatball pattern because
of the presence of hyphae and spores.1,2,4,6 Of mention, fungal
cultures will lead to negative results because the fungus does
not contain the lipids required for growth in culture media.5
The most common fungi responsible for disease include
M. sympodialis (with predilection for the back and chest) and
M. furfur (with predilection for the back and abdomen).7
A history of recurrences during the summer months and/or
heavy sweating is typical, as increased sebaceous gland
involvement causes the humid environment necessary for the
growth of the hyphal form.2,5,8,9 Those with first-degree relatives with pityriasis versicolor may also be more likely to
develop the disease themselves.6
Conversely, tinea corporis (caused most commonly by
Trichophyton rubrum) does not usually show the same pigmentary changes nor similar scaling pattern, but rather an
annular pattern with an elevated rim of scale surrounding a
normal appearing center.1 Both KOH prep and fungal cultures will be positive.1 Hyphae will primarily be present, but
not the combination of spores and short hyphae (spaghetti
and meatball) seen with pityriasis versicolor.4,9 A history
of failed oral antifungals including griseofulvin or terbinafine
is evidence that tinea corporis is likely not responsible.2
In the case of pityriasis rosea, one initial lesion will be
followed weeks later by the appearance of numerous smaller
patches/papules on the back along the skin tension lines in a
Christmas tree pattern and will result in a negative KOH.1,2
It is especially important to rule out pityriasis versicolor
before initiating treatment for either tinea corporis or pityriasis rosea. Otherwise, patients, as in our prior case, may be
unnecessarily prescribed oral treatments that are not only
ineffective, but could lead to harmful side effects.4
When pityriasis versicolor is diagnosed, initial treatment
begins with topicals to include selenium sulfate, 1% clotrimazole cream, 2% ketoconazole shampoo or cream, miconazole
MILITARY MEDICINE, Vol. 178, August 2013

Military Medicine 2013.178:904-906.

Downloaded from publications.amsus.org by 114.4.76.148 on 08/11/16. For personal use only.

Pityriasis Versicolor

FIGURE 1.

Active duty male with pityriasis versicolor.

cream, and terbinafine cream.4,5,10 Of note, 1% terbinafine

cream works well, but is relatively ineffective when used orally
(with minor exceptions such as one subgroup of M. furfur susceptible to oral therapy during experimentation).11,12 Patients
are commonly instructed to apply shampoos daily to monthly,
leaving on the skin for 5 to 10 minutes before washing while
creams are routinely used once to twice daily for 1 month.
Although not routinely used in the United States, beeswax and
honey applied for 3 weeks every 8 hours was also found to
be effective, resulting in a 79% cure.13 Also, adapalene gel,
though commonly used for acne treatment and overall more
expensive, has been shown to eliminate disease, likely through
decreasing sebaceous gland activity, removing abnormal keratin producing cells, and acting as an anti-inflammatory agent.8
Patients should have a fair trial of topical antimycotic shampoos or creams before oral treatment, although even after initially effective therapy, recurrence is common, approaching
an estimated 60%.1,2,10
If topical treatment is ineffective, commonly used oral
medications including ketoconazole, itraconazole, and fluconazole can be tried, although none have been granted U.S.
Food and Drug Administration approval for this condition.4
Most effective treatment regimens include 300 mg oral fluconazole every week for 2 to 4 weeks, 200 mg oral ketoconazole daily for 10 days, and 200 mg oral itraconazole daily
for 7 days.1,4,5,10 Out of these 3 choices, fluconazole is the

safest.4 Of note, single doses of 300 mg oral fluconazole or

400 mg oral ketoconazole followed by a workout to sweat the
medication onto the skin have been commonly used in the
military2; however, single doses are less efficacious than longer
oral treatment options.1,4 Hypopigmentation may last weeks to
months after effective treatment. This hypopigmentation may
lead the patient to think treatment was ineffective; however,
disappearance of the scale is evidence that the hyphal yeast has
likely been eradicated. Thus, sun exposure and time is all
that is necessary for correction of pigmentation changes.46,10
Because of this, the patient may not need oral therapy (with its
respective side effects) for a presumed failed topical trial. Side
effects of oral therapy may include headaches, gastrointestinal
complaints, hepatotoxicity, congestive heart failure, and cytochrome P-450 interactions with other drugs.10 Monitoring
hepatic enzymes and stopping statins and other medications
that may interact should be considered.4,10 Although not
readily available, in those with persistent hyperpigmentation
despite therapy, a 5-day twice daily application of cycloserine
(an inhibitor of TAM 1 enzyme thought to be a key cause
of hyperpigmentation) may be beneficial.6
Military health care providers have additional considerations when diagnosing and treating active duty members,
to include prescribing medications that are easy to use, have
favorable safety profiles, and are cost effective for the military. General Medical Officers and Independent Duty Corpsmen often experience constant turnover in clinics as well as
transitions to fulfill deployment needs. Thus, the importance
of accurate initial diagnoses and adequate medical documentation for continuity in case of failed therapy cannot be
overemphasized. Busy clinics with limited provider coverage, equipment, and testing supplies can make this challenging. Because of similar circumstances faced by military
patients, failure to follow up is common. Patient compliance
is also a challenge, so treatments that are easiest to use, such
as single-dose oral therapies, become quite attractive.2
Because of the previously mentioned challenges, it is
important to use the best means available to make a diagnosis
before prescribing any medications and start with the most
moderate treatment plan first. During deployment to a field
environment, where resources and quad containers are limited,
bulky topical therapies are not practical to stock.2 Therefore,
instead of subjecting a patient to the potential side effects of
oral treatment, in benign conditions with minimal symptoms
such as pityriasis versicolor, it may be best to delay therapy
until the patient returns to a location where topical treatments
are available. Often times with dermatologic conditions, providers may be tempted to use trial-and-error medicine without
a working diagnosis, inadvertently subjecting patients to
unnecessary adverse reactions rather than taking the time to
make the correct diagnosis and provide optimal treatments.
Another consideration is cost to the military. Because of a
less confining health care system, military providers have the
ability to prescribe what is easiest versus what is most effective
for overall health care management. For instance, although all

MILITARY MEDICINE, Vol. 178, August 2013

Military Medicine 2013.178:904-906.
Downloaded from publications.amsus.org by 114.4.76.148 on 08/11/16. For personal use only.

905

Pityriasis Versicolor

have similar efficacy, in the civilian sector a shampoo may cost

$3 versus an oral medication costing $77.10,14 Fortunately,
military pharmacies are working hard to lessen overall costs
by comparing pharmaceutical prices and purchasing in bulk.
Providers can help dampen health care costs by determining
specific medication price differences in their respective military pharmacy. In speaking with Camp Pendleton pharmacy
staff, prices are as follows: 7 days of 200 mg oral itraconazole
at $29.57, 10 days of 200 mg oral ketoconazole at $9.08, and
2 weeks of weekly 300 mg oral fluconazole at $8.33. For
creams (based on 1 month supply applied twice daily with an
estimated 90 g usage) 1% terbinafine cream is the priciest
at $25.44, followed by 1% clotrimazole cream at $17.43, 2%
miconazole cream at $12.24, and 2% ketoconazole cream
at $10.11. Most cost effective are 2% ketoconazole shampoo
(120 mL for 7-day course) at $5.09 and 2.5% selenium sulfide
lotion (120 mL) at $3.64. With these prices in mind, starting
with shampoos and then if no improvement, moving to either
ketoconazole cream or weekly oral fluconazole (with its relatively more favorable side effect profile of the orals)4 would
be preferable.
In addition, there are potential savings associated with an
accurate diagnosis made before initiation of treatment versus
attempting numerous medications as a form of diagnosis by
trial and error. This is especially important in benign conditions where oral therapy is not necessary. However, one must
consider patient compliance and realize that in some cases
providing an oral medication to treat the disease quickly is
most appropriate.2,9 Regardless, because of high recurrences,
the patient should be committed to maintenance therapy for
prevention to see maximal cost savings. Setting expectations
for potentially long-term therapies with each patient are
important before embarking on a treatment plan.
CONCLUSION
Considering all the factors with regards to a transient military
population, each provider must carefully weigh the pros and
cons of providing therapy that is easy, expensive, and with

906

possible side effects versus a more complex, cheap therapy

with a low risk profile in the less compliant patients. This is
especially important pertaining to dermatologic conditions
with several treatment options.
ACKNOWLEDGMENTS
Special thanks to the corpsmen who diligently attend to patients on a daily
basis at Combat Logistics Regimen 17.

REFERENCES
1. Kelly B: Superficial fungal infections. Pediatr Rev 2012; 33(4): e2237.
2. McNally B, McGraw T: Picture this. . . tinea versicolor. J Spec Oper
Med 2010; 10(1): 10710.
3. Han A, Calcara D, Stoecker WV, Daly J, Siegel DM, Shell A: Evoked
scale sign of tinea versicolor. Arch Dermatol 2009; 145(9): 1078.
4. Nevas J: Tinea versicolor: understanding effective treatment options.
Nurse Pract 2012: 37(1): 113.
5. Haisley-Royster C: Cutaneous infestations and infections. Adolesc Med
State Art Rev 2011; 22(1): 12945.
6. Mayser P, Rieche I: Rapid reversal of hyperpigmentation in pityriasis
versicolor upon short-term topical cycloserine application. Mycoses
2009; 52(6): 5413.
7. Petry V, Tanhausen F, Weiss L, Milan T, Mezzari A, Weber MB:
Identification of Malassezia yeast species isolated from patients with
pityriasis versicolor. An Bras Dermatol 2011; 86(4): 8036.
8. Shi TW, Ren XK: Roles of adapalene in the treatment of pityriasis
versicolor. Dermatology 2012; 224(2): 1848.
9. Wahab MA, Ali ME, Rahman MH, et al: Single dose (400mg) versus
7 day (200mg) daily dose itraconazole in the treatment of tinea versicolor:
a randomized clinical trial. Mymensingh Med J 2010; 19(1): 726.
10. Hu SW, Bigby M: Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010; 146(10): 113240.
11. Villars V, Jones TC: Clinical efficacy and tolerability of terbinafine
(Lamisil)a new topical and systemic fungicidal drug for treatment
of dermatomycoses. Clin Exp Dermatol 1989; 14(2): 1247.
12. Leeming JP, Sansom JE, Burton JL: Susceptibility of Malassezia furfur
subgroups to terbinafine. Br J Dermatol 1997; 137(5): 7647.
13. Cherniack EP: Bugs as drugs, Part 1: Insects: the new alternative
medicine for the 21st century? Altern Med Rev 2010; 15(2): 12435.
14. Stratman EJ: Failure to use available evidence to guide tinea versicolor
treatment: comment on pityriasis versicolor. Arch Dermatol 2010;
146(10): 1140.

MILITARY MEDICINE, Vol. 178, August 2013

Military Medicine 2013.178:904-906.
Downloaded from publications.amsus.org by 114.4.76.148 on 08/11/16. For personal use only.