Tinea versicolor: an updated review

Abstract

Background: Tinea versicolor is a common superficial fungal infection of the skin with various clinical manifestations. This review aims to familiarize physicians with the clinical features, diagnosis and management of tinea versicolor.

Methods: A search was conducted in July 2022 in PubMed Clinical Queries using the key terms "tinea versicolor" OR "pityriasis versicolor". The search strategy included all clinical trials, observational studies and reviews published within the past 10 years.

Results: Tinea versicolor is caused by Malassezia species, notably M. globosa, M. furfur and M. sympodialis. The condition is characterized by scaly hypopigmented or hyperpigmented macules/patches, primarily located on the upper trunk, neck and upper arms. The diagnosis is usually based on characteristic clinical features. If necessary, a potassium hydroxide preparation test can be performed to reveal numerous short, stubby hyphae intermixed with clusters of spores. Most patients with tinea versicolor respond to topical antifungal therapy, which has a better safety profile (fewer adverse events, fewer drug interactions) and lower cost compared to systemic treatment and is therefore the treatment of choice. Oral antifungal therapy is typically reserved for patients with extensive disease, frequent recurrences or disease that is refractory to topical therapy. Advantages of oral antifungal therapy include increased patient compliance, shorter duration of treatment, increased convenience, less time involved with therapy and reduced recurrence rates. On the other hand, oral antifungal therapy is associated with higher cost, greater adverse events and potential drug-drug interactions and is therefore not the first-line treatment for tinea versicolor. Long-term intermittent prophylactic therapy should be considered for patients with frequent recurrence of the disease.

Conclusion: Selection of antifungal agents depends on several factors, including efficacy, safety, local availability, ease of administration, likelihood of compliance and potential drug interactions of the antifungal agent.

Keywords: Malassezia species; evoked scale sign; fluconazole; itraconazole; ketoconazole; pityriasis versicolor; selenium sulfide; terbinafine; zinc pyrithione.

Figure 1

Tinea versicolor presenting as multiple hypopigmented macules and patches on the chest (part a) and left shoulder and upper back (part b).

Figure 2

Multiple erythematous macules and patches on the upper abdomen and chest.

Figure 3

Multiple hypopigmented macules and patches on the neck and face of a 5-year-old child (part a) and on the face of a 10-year-old child (part b).

Figure 4

Multiple hypopigmented macules and patches on the left forearm.

Figure 5

Hyperpigmented macules with minimal desquamation on the upper back (part a) and with prominent desquamation on the upper back after the skin lesion was scrapped (the evoked scale sign, part b).

Figure 6

Hyperpigmented macules in the axillary region of a 17-year-old male with tinea InVersicolor.

Figure 7

Confetti-like spots on the left arm, left lateral upper chest and armpit of a child with confetti-like tinea versicolor.

Figure 8

KOH preparation of tinea versicolor showing numerous short, stubby, hyphae intermixed with clusters of spores (the so-called ‘spaghetti and meatballs’ appearance).