This report reflects the best data available at the time the report was prepared, but cau- tion should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.

Guidelines of care for superficial mycotic infections of the skin: Pityriasis (tinea) versicolor

Guidelines~Outcomes Committee: Lynn A. Drake, MD, Chairman, Scott M. Dinehart, MD, Evan R. Farmer, MD, Robert W. Goltz, MD, Gloria F. Graham, MD, Maria K. Hordinsky, MD, Charles W. Lewis, MD, David M. Pariser, MD, John W. Skouge, MD, Stephen B. Webster, MD, Duane C. Whitaker, MD, Barbara Butler, CPA-SDR Consultant, and Barbara J. Lowery, MPH

Task Force: Boni E. Elewski, MD, Chairman, Mervyn L. Elgart, MD, Paul H. Jacobs, MD, Jack L. Lesher, Jr., MD, and Richard K. Scher, MD

I. Introduction Guidelines of Care for Superficial Mycotic Infec- The American Academy of Dermatology's Guide- tions of the Skin: Onychomycosis lines/Outcomes Committee is developing guide- Guidelines of Care for Superficial Mycotic Infec- lines of care for our profession. The development tions of the Skin: Piedra of guidelines will promote the continued delivery of Pityriasis (tinea) versicolor is a superficial infection quality care and assist those outside our profession of the stratum comeum by the yeast Malassezia in understanding the complexities and scope of care furfur (syn. Pityrosporum orbiculare). This yeast is provided by dermatologists. For the benefit of part of the normal cutaneous flora. Pityriasis (tinea) members of the American Academy of Dermatol- versicolor is characterized by hyperpigrnented and ogy who practice outside the jurisdiction of the hypopigmented scaly patches, primarily on the United States, the listed treatments may include trunk and proximal extremities. agents that are not currently approved by the U.S. III. Rationale Food and Drag Administration. A. Scope 11. Definition Pityriasis (tinea) versicolor is a common disor- "Guidelines of Care for Superficial Mycotic In- der that affects people of all age groups, but is fections of the Skin: Pityriasis (Tinea) Versicolor" most commonly seen in adults. Infants and is one of six documents addressing superficial my- children can also be affected, but often have an coses. Companion documents in this series include atypical presentation. This disease is typically the following: worse in geographic areas with tropical ambi- Guidelines of Care for Superficial Mycotic Infec- ent temperatures. Multiple factors are known to tions of the Skin: Mucocutaneous Candidiasis contribute to its pathogenesis. Guidelines of Care for Superficial Mycotic Infec- B. Issue tions of the Skin: .Tinea Corporis, Tinea Cruris, Involvement of the cutaneous surface can oc- Tinea Faciei, Tinea Manuum, and Tinea Pedis casionally be extensive, leading to emotional Guidelines of Care for Superficial Mycotic Infec- distress because of appearance. Symptoms tions of the Skin: Tinea Capitis and Tinea Bar- vary from none to severe pruritus. Although bae numerous therapies are available, recurrences frequently occur after treatment, especially in Reprint requests: AmericanAcademy of Dermatology, P.O. Box4014, tropical climates. Schaumburg, IL 60168-4014. (Providedfree of charge) IV. Diagnostic criteria J AM ACADD~ra~TOL 1996;34:287-9. A. Clinical Copyright 1996 by the American Academyof Dermatology,Inc. 1. History may include the following: 0190-9622/96 $5.00+ 0 16/1/69828 a. General medical condition, especially if 287 Journal of the American Academy of Dermatology 2,88 Drake et al. February 1996

use of oral antifungals is considered, examination, the diagnosis can often be estab- may include the following: lished. Greater diagnostic accuracy occurs ff t) Hepatic disease the clinical diagnosis is verified by laboratory 2) Renal disease tests. This verification is especially important 3) Endocrine disease--diabetes melli- when the use of systemic therapy is anticipated. tus Simple, inexpensive tests that can be performed 4) Use of systemic medications in the physician's office at the time of the pa- 5) Other tient visit may yield immediate results. Such b. Duration, progression to point of max- tests include, but are not limited to, the follow- imal severity ing: c. Seasonal variation 1. Potassium hydroxide preparation (KOH) d. Current treatment(s), topical and sys- Scale from the affected area is placed on a temic, of glass slide, and 10% to 15% KOH is added 1) Pityriasis versicolor with or without dimethyl sulfoxide 2) Other diseases (DMSO). If DMSO is included, gentle e. Past treatment(s), topical and systemic, heating is generally not necessary. A fungal of stain such as Chlorazol Black E, or Parker's 1) Pityriasis versicolor blue-black ink may be added to highlight 2) Other diseases the hyphae and yeast cells. A confirmatory f. Other skin disorders, especially but not KOH preparation would reveal short, limited to the following: stubby hyphae and yeast cells. Patients may lj' Atopy, personal or familial (because have a predominance of either. of occasional irritation to topical an- 2. Wood's light examination to demonstrate tifungal agents) extent of involvement 2) Seborrheic dermalilis 3. Other stains g. Drug allergies Other stains may be used to identify the h. Habitual use of heavy oils on skin hyphae and yeast cells. These stains in- i. Other chde, but are not limited to, the following: 2. Physical examination may include the fol- a. Paragon multiple stain lowing: b. Other a. General physical examination as indi- 4. Studies for differential diagnosis may in- cated elude the following: b. Location a. Fungal culture to exclude other my- 1) Anterior aspect of the chest coses M. furfur does not grow on rou- 2) Back fine agars without growth supplements 3) Extremities and is therefore not routinely cultured. 4) Face, neck (more common in chil- b. Skin biopsy to differentiate pitydasis dren) versicolor from other dermatoses c. Clim'cal appearance c. Other 1) Hyperpigr~nted lesions 5. Other 2) Hypopigmented lesions C. Inappropriate diagnostic tests 3) Erythematons lesions Routine allergy testing d. Extent of involvement D. Exceptions e. Gradation Not applicable 1) Mild E. Evolving diagnostic tests 2) Moderate Not applicable 3) Severe V. Recommendations f. Associated findings A. Treatment 1) Posfinflammatory hyperpigmenta- Topical treatment alone may be indicated for tion and hypopigmentation most patients. Systemic treatment may be indi- 2) Pruritus cated for persons with extensive involvement, 3) Excoriations with recunent infections, and in whom topical 4) Other agents as sole therapy have failed. Systemic g. Other therapy may be used with or without topical B. Diagnostic tests agents or may be used alone in patients intol- After review of the patient history and physical erant to topical treatment. Journal of the American Academy of Dermatology Volume 34, Number 2, Part 1 Drake et al. 289

1. Medical VII. Disclaimer a. Topical antifungal products include, but Adherence to these guidelines will not ensure suc- are not limited to, the following: cessful treatment in every situation. Further, these 1) Imidazoles guidelines should not be deemed inclusive of all 2) Ciclopirox olamine proper methods of care or exclusive of other meth- 3) Miscellaneous ods of care reasonably directed to obtaining the a) Selenium sulfide shampoos, lo- same results. The ultimate judgement regarding the tions propriety of any specific procedure must be made b) Zinc pyrithione shampoos by the physician in light of all the circumstances c) Sulfur preparations presented by the individual patient. For the benefit d) Salicylic acid preparations of members of the American Academy of Derma- e) Propylene glycol lotions tology who practice outside the jurisdiction of the f) Benzoyl peroxide United States, the listed treatments may include g) Other agents that are not currently approved by the U.S. 4) Other Food and Drug Administration. b. Systemic therapy (see V.A. above) 1) Ketoconazole Appendix. Bibliography 2) Evolving Albright SD, Hitch JM. Rapid treatment of tinea versicolorwith a a) Fluconazole selenium sulfide shampoo. Arch Dermatol 1965;93:460-2. b) Itraconazole Bickers DR. Anfifimgal therapy: potential interactions with other classes of drugs. J AM ACAI9DERMATOL 1994;31;$87-90. Other c) Brodell RT, Elewski BE. Clinical Pearl: systemic antifungal drugs 3) Other and drug interactions. J AM ACADDERMATOL 1995;33:259-60. 2. Surgical Delescluse J. Itraconazolein tinea versicolor, a review. J AM Ao_Ao Not applicable DERMATOL1990;23:551-4. 3. Other Faergemann J. Treatmentof pityfiasis versicolorwith itraconazole: a double-blind placebo-controlled study. Mycoses 1988;31: B. Miscellaneous 377-9. 1. Follow-up Faergemann J, Djarv L. Tinea versicolor, treatment and prophy- Follow-up examinations may be indicated, laxis with ketoconazole. Curls 1982;30:542-5, 550. depending on extent, severity, and tolerance Faergemann J, FredriekssonT. An open trial of the effect of a zinc to medications, as well as the need to aug- pyrithioneshampoo in tinea versicolor.Curls 1980;25:667,669. Faergemann J, FredrikssonT. Propyleneglycol in the treatment Of ment or alternate treatment on the basis of tinea versicolor. Acta Derm Venereol (Stockh) 1980;60:92-3. clinical response. Intervals between visits Gupta AK, Sauder DN, Shear NH. Anfifungalagents: an overview. will vary, depending on, but not limited to, Part I. J AM ACAD DERMATOL1994;30:677-98. the severity of the problem and the intensity Gupta AK, Sauder DN, Shear NH. Antifungalagents: an overview. of the treatment. Part IL J AM AcAD DF.RMATOL1994;30:911-33. Hay RJ. Antifungal drugs on the horizon. J AM ACADDERMATOL 2. Monitoring of patients receiving systemic 1994;31:$82-5. therapy Hay RJ, Midgeley G. Short course ketoconazoletherapy in pityr- Periodic monitoring of hepatic, renal, and iasis versicolor. Clin Exp Dermatol 1984;9:571-3. hematopoietic function may be indicated in Hemgmdez-P6rezE. A comparison between one and two weeks' patients treated with systemic antifungals. treatment with bifonazole in pityriasis versicolor. J AM ACAD DERMATOL 1986;14:561-4. 3. Drug interactions Lesher JL Jr, Smith JG Jr. Antifungalagents in dermatology.J AM Oral antifungals have the potential for sig- ACAD DERMATOL1987;17:383-94. nificant drug interactions and toxicities. Physicians' Desk Reference. Montrale, NJ: Medical Economics, The package insert and the Physician's 1995. DeskReferenee (PDR ) should be consulted. Rausch LJ, JacobsPH. Tinea versicolor,treatment and prophylaxis with monthly administration of ketoconazole. Cuffs 1984; 4. Contraindications and precautions for use 34:470-1. of systemic antifungal therapy Savin RC, Horwitz SN. Double-blindcomparison of 2% ketoeon- a. Hypersensitivity to medication azole cream and placebo in the treatment of tinea versicolor. J b. Precautions (see package insert and the AM ACAODERMATOL 1986;15:500-3. PDR) Svejgaard E. Double-blindtrial of miconazolein dermatomycosis. Acta Derm Venereol (Stockh) 1973;53:497-500. c. Other Zaias N. Pityriasis versicolorwith ketoconazole.J AM ACADDER- VI. Supporting evidence MATOL 1989;20:703-4. See Bibliography (Appendix)