Pityriasis versicolor

Last Updated: 2021-10-18

Author(s): -

Eichstedt 1846.

Pityriasis versicolor flava, Pityriasis versicolor alba, Pityriasis versicolor rubra, Tinea versicolor (the term no longer in use).

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

  • Frequent mycosis of the skin 
  • Prevalence in Europe is up to 4%.
  • In countries around the equator the prevalence is up to 40% in some cases
  • Mostly adolescents and young adults are affected 
  • The disease is caused by lipophilic yeasts of the genus Malassezia, which grow particularly in a warm and humid environment and are part of the regular skin flora. When pityriasis versicolor flares up, the otherwise absent mycelium is formed.
  • A 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: Taking glucocorticosteroids or contraceptives, severity, genetics and atopic dermatitis
  • The clinical features vary
  • Small to large confluent, tinsel like, round or oval, yellowish to brownish, partly white macular or thin plaques with discrete scaling
  • Characteristic is the change in colour after UV exposure (in summer, lighter and in winter darker fluorescence than the rest of the skin)
  • No pruritus, but a feeling of tension is possible 
  • Plane chip phenomenon: pityriasiform scaling when coating the efflorescence with a wooden spatula
  • In immunocompromised patients, increased severity or follicular-bound progression may be associated with folliculitis
  • Special forms
    • Pityriasis versicolor chromians: distinctly hyperpigmented form
    • Pityriasis versicolor punctata: follicular form
    • Pityriasis versicolor flava: caused by Malassezia tropica
    • Pityriasis versicolor nigra: Lesions are partly blackish with follicularly bound nodules. A regression is possible under UV exposure. 
    • Hyperkeratotic malassezia: occurs mainly on the face and nuchal
  • Medical history incl. travel history 

  • Clinical features (gaze diagnosis)

  • Fungus detection by means of a native adhesive strip preparation, whereby on the one hand, there is the possibility of a Parker colouring with potassium hydroxide solution and ink (1:1), as well as direct microscopic examination. So-called "spaghetti with meatballs" are shown, which correspond to the hypotheses and spore clusters of the yeast fungus 

  • In the case of Malassezia furfur in particular, wood light is also suitable as a method of detection due to the pigments and fluorochromes formed with tryptophane in this genus 

  • A culture is not useful 

  • Preferably glandular areas of the trunk
  • Inner thigh
  • Inner side of upper arm
  • The face is often affected in children 

PAS staining is essential for detection! Spores and hyphae are found in intracorneal.

  • 2-5% Salicylic acid skin spirit (R218)
  • Itraconazole 400mg in two doses of 200mg once a month for 6 months 

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

  • Educating 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. The therapy should be carried out for a total of 3 days.
  • Alternative: 2.5% saline sulfide
  • Alternative: 20% propylene glycol
  • At the same time an antimycotic treatment of the capillary should be carried out
    • Ketoconazole-containing shampoo: 3 applications, please allow 5-10 minutes before rinsing
    • Alternatively Ciclopirox-containing shampoo: 3 applications, allowing 5-10 minutes before rinsing
  • Pregnancy: Only Nystatin is approved

 

  • In case of continuous recurrence under external therapeutics a 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 daily for 14 days
    • Alternative: Ketoconazole p.o. 200mg 1x daily for 10 days or 400mg 1x a month
    • Systemic Terbinafine shows no effect 

 

Therapy according to Lebwohl

1st choice

Evidence level after Lebwohl
Ketoconazole A
Bifonazole A
Terbinafine A
Clotrimazole A
Econazole A
Oxiconazole A
Butenafine A
Ciclopirox A
Fluconazole Shampoo A
Selenium sulfide 2,5% B
Tioconazole B
Zink-Pyrithione B

 

2nd choice

Evidence level after 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)