Pityriasis (Tinea) Versicolor (1 of 5)

1 Patient presents w/ hyper- or hypopigmented macules w/ ﬁne scales suggestive of pityriasis (tinea) versicolor

2 Do clinical presentation & No ALTERNATIVE microscopy conﬁrm DIAGNOSIS pityriasis (tinea) versicolor?

Yes

A Non-pharmacological therapy • Patient education B Pharmacological therapy Topical Antifungal Any one of the following: • Amorolfi ne • Butenafi ne • Ciclopirox • Imidazoles • Ketoconazole • Naftifi ne • Selenium sulfi de • Terbinafi ne • Tolnaftate • Zinc pyrithione Oral Antifungal (consider for severe or widespread disease) Any one of the following: • Fluconazole • Itraconazole © MIMS

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

B307 © MIMS 2019 PITYRIASIS VERSICOLOR • • • • • • Referral: foraDermatology Considerations • • Diagnosis Alternative • • Wood’s Exam Light • • Culture • • • Microscopy • • • • • • • • Presentation Clinical • superfi versicolor acommon, is (tinea) benign, Pityriasis to the stratum corneum localized infection fungal cial Consideration of long-term antifungal prophylaxis antifungal Consideration oflong-term Immunocompromised patients Consideration therapy oforalantifungal inchildren <12years Treatment setting care inprimary failure infection &severe Extensive diagnosis &unclear microscopy Negative Tinea corporis syphilis, secondary Other conditions w/ similar appearance to disorders thatCommon are non-fluorescent under Wood’s alba pityriasis Vitiligo, light: guttate psoriasis, However, towhitefl yellowish uorescence isindicative onlyinapproximately 1/3ofcases lesions subclinical todetect used May be Diffi instandard mycological media Malassezia cult togrow forroutine diagnosis Unnecessary acid-schiff stainwell also w/periodic species Malassezia (PAS) ormethenamine silver Calcofl offl butthis utilization requires technique used uor may be uorescence microscope “spaghetti the typical cells as appear stubby hyphae &yeast Short will &meatballs” appearance - addingadrop under of10-20%KOH light ordebris after are solution microscope examined Scales - Potassium hydroxide (KOH) shouldconfi examination ofskinscrapings the rm diagnosis Planning treatment oralantifungal - antifungals topical tothe regular isunresponsive Infection - isunclear Diagnosis - if: Consider doingmicroscopy forthe diagnosis isnotusuallyneeded testing Lab donottanalongthe skin normal Lesions face &arms &may the extend neck, towards back &shoulders, chest, Usually foundonthe trunk, upper Tends &ismainlyacosmetic concern asymptomatic may tobe butpruritus present ormay notbe hyperpigmentation, hence the “versicolor” term w/multiplePresents well-demarcated orpatches macules &fi w/hypopigmentation plaques or nely scaled when the inyoungadults sebaceousPredominates active glandsare most More common insummer than winter months - May chronic &may present orrecurrent as occur infection inhealthy individuals ofthe fl normal part species, Malassezia yeasts, lipophilic by Caused ora ofthe human skin © MIMS Pityriasis (Tinea) Versicolor (2of5) : Erythrasma, Tinea: Erythrasma, versicolor 1 2 EVALUATION DIAGNOSIS B308 , seborrheic dermatitis, rosea, dermatitis, seborrheic Pityriasis © MIMS 2019 • Patient Education • • • • • • (Tinea) Versicolor Factors that PromotePityriasis Risk Infection: • • • Systemic erapy • • • • • • • Topical Antifungals • • • • Initial erapy • • • - growth Educate patient ofyeast the about basics Oral corticosteroid intake orCushing’s disease predisposition Immunocompromised state, malnutrition &hereditary Excessive sweating Oily skinorapplication ofoilstoskin Occlusive clothing Prominent regions &subtropical intropical - High temperature &highhumidity lotions&other cosmetic products Avoid creams, ofocclusive clothing, use - It isneither hygiene contagious norduetopoor - Oral Itraconazole is also used for prophylaxis ofrecurrences for prophylaxis Oral Itraconazole used isalso agentsOral antifungal Itraconazole &Fluconazole are preferred therapy oftopical &failure skininvolvement, recurrent orwidespread infections, ofsevere incases Indicated - steroid/imidazole agentsCombined Highlyeff inexpensive safe&fairly ective, - Imidazoles - eff Proven tobe for1st-line &safe;inexpensive ective therapy - Selenium sulfi pyrithione de &Zinc - Terbinafi ne Topical application isproven eff twice dailyfor2weeks when used ective - Ciclopirox duration oftherapy, relapse low rate &cost-effectiveness Higheffi properties: Desirable cacy, favorable eff adverse profiects shortest dailyapplications, possible le, fewest initialtreatment as Used eff adverse possible peroxide considered may about butpatient be informed shouldbe touse prior ects agentsOther topical Whitfi such as eld ointment, Sulfur-Salicylic Propylene glycol, acidshampoo, &Benzoyl May treatment consider therapy topical systemic repeat starting before - confiIf initialtherapy fails, adherencerm totreatment children inboth &adults used may creams Imidazole be - ofskininvolvement forsmallareas isadvised cream Antifungal SeleniumMay sulfi use shampoo de orKetoconazole Topical eff very agents be can inchildren especially &are safer medications, thanective systemic additionaltreatment warrant palepatches Ifmycology persisting donotnecessarily isnegative, - complete after treatment toresolve Skin discoloration weeks may takeseveral - individuals Treatment isusuallyeff insusceptible duetorecurrence ofinfection butmay repeated haveective tobe

species are lipophilic; advise patient advise are toavoid lipophilic; tothe oilsapplied skinorinthe bath species Malassezia ©of significant infl ammation inthis condition &the potential ofthe steroid component toinduce atrophy duetothe absence versicolor (tinea) steroid combination fortreating Pityriasis isnotindicated High-potency rinsing) before maintenance as (apply regimen used on theMay 1st & 3rd be day month of each & leave onfor5minutes EffiMIMS application oftopical iscomparable effcacy surpass &may even infections tinea against ofimidazoles ect humid conditions Prophylactic treatment forpatients isrecommended tosunlight at ofrecurrence orwarm risk onexposure Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing A NON-PHARMACOLOGICAL THERAPY B Pityriasis (Tinea) Versicolor (3of5) PHARMACOLOGICAL THERAPY B309 © MIMS 2019

PITYRIASIS VERSICOLOR PITYRIASIS VERSICOLOR Ketoconazole 200 mg PO 24hrly x7-10 200mgPO Ketoconazole Itraconazole Fluconazole 50 mg PO 24hrly x2-4wk 50mgPO Fluconazole Clotrimazole 1% soln, lotn, cream, lotn,cream, 1%soln, Clotrimazole Bifonazole Imidazoles Butenafi ne Benzylamine Terbinafi ne Eoaoe1%cream Econazole Naftifi ne Allylamines Drug rgAalbeSrnt Dosage Available Strength Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products days days 24hrly x5-7 100-200 mgPO wk once wklyx2 or 300mgPO placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed spray, powd 1% soln,cream 1% cream spray gel, cream, 1% soln, 1% cream & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Pityriasis (Tinea) Versicolor (4of5) ANTIFUNGALS (TOPICAL) Dosage Guidelines ANTIFUNGALS (ORAL) Apply 8-12hrly Apply 24hrly 2-4 wk Apply 24hrly x 1-2 wk Apply 12hrly x Apply 12-24hrly Apply 12-24hrly • • Reactions Adverse • Reactions Adverse • Instructions Special • Reactions Adverse B310 - Fatal liver damage eff itching); CNS urticaria, (rashes, (headache) ect GI eff (N/V,ects eff pain);Dermatological abdominal ects Other eff failure) heart (pruritus, ects treatment eff >1mth); CNS dizziness); (headache, ects jaundice if hepatitis, transaminases, (elevation ofserum GI eff (N/V,ects pain),Hepatic eff abdominal diarrhea, ects Tacrolimus, etc short-acting benzodiazepines, oralanticoagulants, Rifampicin, hypoglycemics, interactions ofdrug w/ oral Monitor forsymptoms fever, transaminases) serum sweating, elevated pruritus, Other eff insomnia); (headache, (palpitations, ects GI eff pain,N/V, (abdominal ects eff CNS diarrhea); ects

Risk ofliverdamageincreasesifgivenfor>14days • Instructions Special • Reactions Adverse • Reactions Adverse • Reactions Adverse • Reactions Adverse Treat stated otherwise for2-3wkunless pruritus) erythema, sensation, mildburning reactions, hypersensitivity irritation, local effDermatological (occasional ects itching) irritation, erythema, sensation, burning/stinging dermatitis, effDermatological (contactects sensation, itching)stinging effDermatological (redness, ects pruritus) sensation, erythema, stinging effDermatological (burning/ ects Remarks Remarks © MIMS 2019 1 Various combinations acidare available. Specifi &strengths ofSalicylic information foundinthe may latest MIMS. be c prescribing F nioaoe2 ra,sryApply 12-24hrly spray 2%cream, Fenticonazole (Cont’d)Imidazoles acid Salicylic Ciclopirox olamine) ( Ciclopiroxolamine, Ciclopirox Apply 12-24hrly Amorolfi ne 2%cream Others Tioconazole Sertaconazole Miconazole Apply 12-24hrly 2%gel, cream Ketoconazole Isoconazole icPrtin 1%liqd Pyrithione Zinc Tolnaftate 2.5%lotn, Selenium sulfide Drug 1 Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, are for & non-breastfeeding non-pregnant All recommendations dosage © MIMS 1.5% liqd Apply & rinse after 3-5 Apply after &rinse 1.5% liqd Apply 12-24hrly cream 0.25%, 0.5% 1% cream cream tinct, powd, 2% soln, 2% shampoo Apply 24hrly soln 1%, 2%scalp 1% cream tinct 3% soap, 4% oint cream, 1% soln, susp shampoo, Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Available Strength Please see the end of this section for the reference list. reference the for section this of end the see Please ANTIFUNGALS (TOPICAL)(CONT’D) Pityriasis (Tinea) Versicolor (5of5) Dosage Guidelines min, 2-3x/wk Apply 24hrly x2-3wk Apply 12-24hrly toexposure prior Apply 24hrly x3days To recurrence: prevent twice wklyx2-4wk 5 days off orapply &rinse Apply off &rinse 24hrly x Apply 8-12hrly Apply 8-12hrly x2-3wk Apply 8-12hrly x2-3wk min once amth Apply off &rinse 5-10 after To recurrence: prevent min 24hrly x7days Apply off &rinse 5-10 after B311 Dosage • Instructions Special • Reactions Adverse • Reaction Adverse • Reactions Adverse • Reactions Adverse • Reactions Adverse • Reactions Adverse • Reactions Adverse otherwise stated otherwise Treat for2-3wkunless pruritus) erythema, sensation, mild burning irritation, (occasional local effDermatological ects sensation, pain) burning redness, (pruritus, effDermatological ects sensation) burning slight pruritus, (erythema, effDermatological ects irritation) effDermatological (skin ect irritation, rashes) irritation, effDermatological (skin ects contact dermatitis) pruritus, sensation, stinging (irritation, effDermatological ects pruritus) sensation, erythema, hypersensitivity, mildburning irritation, (occasionally local effDermatological ects Remarks © MIMS 2019

PITYRIASIS VERSICOLOR