Pityriasis Versicolor-A Narrative Review on the Diagnosis and Management

Abstract

This narrative review presents a comprehensive overview of the diagnosis and management of pityriasis versicolor (PV), a common superficial fungal infection caused by the yeast Malassezia. PV is characterised by scaly hypopigmented or hyperpigmented patches, primarily affecting the upper trunk, neck, and upper arms. Regarding commensal interactions, Malassezia utilises nutrient sources without affecting the human host. In cases of pathogenicity, Malassezia can directly harm the host via virulence factors or toxins, or indirectly by triggering damaging host responses. The diagnosis typically relies on recognising characteristic clinical features. Due to the wide variability in its clinical presentation, recognising the differential diagnosis is critical. In this paper, we discuss the clinical differentials, with their dermatoscopic presentation, but also describe a range of helpful diagnostic techniques (microscopy, conventional and ultraviolet-induced fluorescence dermatoscopy, and confocal microscopy). Topical therapies are the primary treatment for PV, encompassing non-specific antifungal agents like sulphur with salicylic acid, selenium sulphide 2.5%, and zinc pyrithione. Additionally, specific topical antifungal medications with either fungicidal or fungistatic properties may also be incorporated into the topical treatment regimen, such as imidazoles, allylamines, and ciclopirox olamine. Systemic therapies might occasionally be used. Patient education and the promotion of good personal hygiene are pivotal to reduce the risk of recurrence. In recurrent cases, particularly during warmer and more humid periods, prolonged prophylaxis with topical agents should be considered.

Keywords: Malassezia; Pitryrosporum; confocal microscopy; dermatoscopy; fungal infections; imaging; microscopy; tinea versicolor; treatment; ultraviolet radiation; yeast.

Figure 1

Variability of clinical presentations of pityriasis versicolor (PV). (A) Hyperpigmented confluent roundish erythemo-desquamative PV macules over the abdomen in a young man. (B) Discrete, achromic confluent PV macules affecting the shoulders and interscapular areas in a young man. (C) Depigmented PV spots on the back in middle-aged women. (D) Discrete, confetti-like PV depigmented spots on the back of an elderly woman. (E) Isolated hyperpigmented “tinea InVersicolor” on the pubis in a young man. (F) Roundish, depigmented macules on the face of a young boy. (G) Minute reddish scaly spots over the neck in a young female. (H) Confluent red scaly macules covering the neckline and presternal area, imitating confluent and reticulated papillomatosis.

Figure 2

Direct microscopic examination of the skin scrapings reveals yeast cells and hyphal fragments (spaghetti and meatballs appearance), Magnification 200× (A). Lactophenol cotton blue stain (LPCB) used to enhance the visibility of hyphae and spores, Magnification 400× (B).

Figure 3

Typical epidermis and dermis with no signs of inflammatory infiltrates or other pathological characteristics. Notably, there is a thickened but loosely arranged stratum corneum. Within this layer, clusters of short longitudinal filaments (resembling hyphae or mycelium) are visible. These filaments occasionally form short branching chains (reminiscent of spaghetti) and round spores resembling yeast cells (meatballs), which can be observed interspersed between the keratin layers. Magnification 20×.

Figure 4

Characteristic basophilic hyphae and spores responsible for spaghetti and meatballs appearance in histopathology. Magnification 40×

Figure 5

Excited ochre and blue fluorescence seen with Wood’s lamp examination in classic (A) and follicular (B) forms of pityriasis versicolor, respectively.

Figure 6

Reflectance confocal microscopy of pityriasis versicolor. Malassezia spores/meatballs (red arrow) and hyphae/spaghetti (yellow arrow) present in the stratum corneum (A). Presence of fungi can induce secondary morphological changes: hyperkeratotic plug (red arrow) inside the hair follicle (B); elongated vessels (red arrow) and vessels inside papillae (yellow arrow) present at the same level as the lower epidermal layers (C); epidermal spongiosis (yellow arrow) (D). Magnification 500×

Figure 7

Dermatoscopy in pityriasis versicolor. (A) Classic hypopigmented lesion of pityriasis versicolor (PV) displaying typical furrow scaling. (B) Follicular hyperpigmented PV displaying small, roundish, folliculocentric tan areas with discrete scaling. (C) Hyperpigmented folliculocentric PV lesion exhibiting reddish-tan area with perifollicular, furrow, and peripheral inward scaling. (D) Hyperpigmented PV with subtle furrow scales and perifollicular scale. (E) Hyperpigmented classic PV lesion with no scale. Peripheral hypopigmented area surrounding the lighter centre (“contrast halo sign”) can be appreciated. (F) Hypopigmented PV exhibits diffuse scaling and peripheral hyperpigmented areas (“contrast halo sign”).

Figure 8

Ultraviolet-induced fluorescence dermatoscopy (UVFD) of pityriasis versicolor (PV). (A) Light greenish excited fluorescence is emitted by fungal chromophore (pityrialactone), which results in emergence of single- or double-edged furrow scale and perifollicular scaling, which seem to be better seen in hypopigmented PV lesions. The image matches Figure 7A. (B) Light greenish perifollicular scale can be appreciated in active follicular PV strongly enhancing the diagnostic clues of scale. The figure matches Figure 7B. (C) UVFD in a case of achromic PV at seborrheic site displays “blackout areas”—areas deprived of background pink-orange porphyrin fluorescence, possibly due to antibacterial properties of azelaic acid produced by Malassezia spp. (D) Dark greenish fluorescence of folliculocentric hyperpigmented PV lesion. Subtle peripheral free edge of scale is seen better with UVFD. The figure matches Figure 7C (E) A case of hyperpigmented PV lesion showing no fluorescence in UVFD. The figure matches Figure 7D. (F) “UVFD contrast halo sign” showing dark curvilinear border enclosing hypopigmented PV.