Pityriasis versicolor

Last Updated: 2022-02-25

Author(s): Anzengruber F., Navarini A.

ICD11: 1F2D.0

Eichstedt 1846.

Pityriasis versicolor flava, pityriasis versicolor alba, pityriasis versicolor rubra, tinea versicolor (term no longer in use)

Common, benign, non-inflammatory and non-infectious superficial mycosis caused by lipophilic yeasts of the genus Malassezia with increased incidence during warm seasons, in adolescents and young adults with localisation on the trunk. The eponymous colour change after UV exposure is characteristic.

  • Frequent mycosis of the skin
  • In Europe, the prevalence is up to 4%
  • In countries around the equator, the prevalence is sometimes up to 40%
  • Mostly adolescents and young adults are affected

  • The disease is caused by lipophilic yeasts of the genus Malassezia, which grow especially in warm, humid environments and are part of the regular skin folra. In the outbreak of pityriasis versicolor, there is otherwise absent mycelium formation.
  • Human-to-human transmission is not known.
  • 14 Malassezia species are known
    • Malassezia globosa mainly in India (90% of diseases, most prominent form)
    • Malassezia furfur mainly in Europe
    • Malassezia sympodialis mainly in Argentina, also found in India
    • Malassezia pachydermatis
  • Predisposing factors include:
    Hyperhidrosis oleosa, warm and humid macro-climate, seborrhoea, impaired skin evaporation, stress, obesity, immunosuppression, use of oily skin care products,
  • The following factors are discussed as possible triggers: Use of glucocorticosteroids or contraceptives, gravidity, genetics and atopic dermatitis

  • The clinic is varies
  • Small to large confluent, tinsel-like, round or oval, yellowish to brownish, sometimes white macules or thin plaques with discrete scaling
  • Characteristic is the colour change after UV exposure (in summer, lighter, in winter darker effluorescences present than the rest of the skin)
  • No pruritus, but a feeling of tightness is possible
  • Scaling phenomenon: pityriasiform scaling when brushing the efflorescence with a wooden spatula
  • In immunosuppressed patients, an intensified expression or follicular bound progression accompanied by folliculitis may occur
  • Special forms
    • Pityriasis versicolor chromians: markedly hyperpigmented form
    • Pityriasis versicolor punctata: follicular form
    • Pityriasis versicolor flava: triggered by Malassezia tropica
    • Pityriasis versicolor nigra: lesions are partly blackish with follicularly bound nodules. Regression is possible under UV exposure.
    • Hyperkeratotic malassezia: occurs mainly on the face and nuchal

  • Anamnesis incl. travel anamnesis
  • Clinical manifestation (visual diagnosis)
  • Detection of fungus by means of a native adhesive strip preparation, with the possibility of staining according to Parker using potassium hydroxide solution and ink (1:1), as well as direct microscopic examination. So-called "spaghetti with meatballs" appear, which correspond to the hypthes and spore clusters of the yeast fungus
  • In the case of suspicion of Malassezia furfur, the wood light is also suitable as a detection method due to the pigments and fluorochromes formed with tryptophan in this genus
  • A culture is not useful

  • Preferably areas of the trunk rich in day glands
  • Inner thigh
  • Inner side of upper arm
  • In children, the face is often affected

PAS staining is essential for detection! Intracorneal spores and hyphae can be found.

  • 2-5% salicylic acid skin alcohol
  • Iraconazole 400mg in two doses of 200mg each 1 time Monthly for 6 months

It is a chronic condition with remission or exacerbation possible at any time. Recurrences are common.

  • Inform the patient
  • Econazole cream (e.g.: Pevaryl cream 1 %): Apply 1-2 times daily to affected skin areas. The therapy should be carried out for a total of 3 days
  • Alternatively: Ciclopirox cream or solution: apply 2x daily to affected skin areas. In total, the therapy should be carried out for 3 days.
  • Alternatively: 2.5% salt sulphide
  • Alternatively: 20% propylene glycol
  • At the same time, an antifungal co-treatment of the capilitium should be given
    • Ketoconazole-containing shampoo: 3 applications, observing a contact time of 5-10 minutes before rinsing
    • Alternatively Ciclopirox-containing shampoo: 3 applications, observing a contact time of 5-10 minutes before rinsing.
  • Pregnancy: Only nystatin is approved

 

  • In case of continuous recurrences under external therapeutics, systemic therapy can be discussed:
    • Itraconazole p.o. 200 mg 1x daily for 5-7 days or 400mg 1x monthly
    • Alternative: Fluconazole p.o. 50 mg 1x tgl. for 14 days
    • Alternatively: Ketoconazole p.o. 200mg 1x tgl. for 10 days or 400mg 1x monthly
    • Systemic terbinafine shows no effect

 

Therapy according to Lebwohl

Medicine of 1st choice Evidence level according to Lebwohl
Ketoconazole A
Bifonazole A
Terbinafine A
Clotrimazole A
Econazole A
Oxiconazole A
Butenafine A
Ciclopirox A
Fluconazole shampoo A
Selenium sulphide 2.5% B
Tioconazole B
Zinc pyrithione B

 

Medicine of 2nd choice Evidence level according to Lebwohl
Itraconazole A
Ketoconazole A
Fluconazole A
Oral prophylaxis  
Itraconazole A

 

  1. Crespo Erchiga, V., et al., Malassezia globosa as the causative agent of pityriasis versicolor. British Journal of Dermatology, 2000. 143(4): p. 799-803.
  2. Crespo-Erchiga, V. and V.D. Florencio, Malassezia yeasts and pityriasis versicolor. Current Opinion in Infectious Diseases, 2006. 19(2): p. 139-147.
  3. Faergemann, J., Management of Seborrheic Dermatitis and Pityriasis Versicolor. American Journal of Clinical Dermatology, 2000. 1(2): p. 75-80.
  4. Gaitanis, G., 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. 154(5): p. 854-859.
  5. Gupta, A.K., et al., Pityriasis versicolor. Dermatologic Clinics, 2003. 21(3): p. 413-429.
  6. Gupta, A.K., R. Bluhm, and R. Summerbell, Pityriasis versicolor. Journal of the European Academy of Dermatology and Venereology, 2002. 16(1): p. 19-33.
  7. Hu, S.W. and M. Bigby, Pityriasis Versicolor. Arch Dermatol, 2010. 146(10).
  8. Wagner, G., C. Diaz, and W. Weyers, Pityriasis versicolor unter dem klinischen Bild einer Papillomatosis confluens et reticularis. Aktuelle Dermatologie, 2004. 30(4): p. 114-119.
  9. AMBOSS Kapitel Pityriasis versicolor
  10. Altmeyer Enzyklopädie Kapitel Pityriasis versicolor 
  11. Braun-Falco Kapitel Oberflächliche Mykosen 
  12. UpToDate Kapitel Tinea versicolor (pityriasis versicolor)