Pityriasis (Tinea) Versicolor (1 of 4) 1 Patient presents w/ various colored macules (hyper- or hypopigmented, erythematous) w/ fine scales suggestive of pityriasis (tinea) versicolor 2 DIAGNOSIS Do clinical presentation & No ALTERNATIVE microscopy confirm DIAGNOSIS tinea versicolor? Yes A Patient education B Pharmacological therapy Topical Antifungals Any one of the following: • Ketoconazole • Imidazole • Butenafi ne • Ciclopirox • Tolnaftate • Naftifi ne • Selenium sulfi de • Terbinafi ne Oral Antifungals (consider for severe or widespread disease) Any one of the following: • Fluconazole • Itraconazole • Ketoconazole © 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. B190 © MIMS Pediatrics 2019 Pityriasis (Tinea) Versicolor (2 of 4) 1 CLINICAL PRESENTATION • Common, benign, superfi cial fungal infection localized to the stratum corneum - Occurs most commonly in postpubertal individuals when the sebaceous glands are the most active • Facial involvement is common in adolescents, but lesions are also found on the upper trunk, neck, arms, dorsum of the hand & pubis - Although sometimes it is generalized • Patient presents w/ erythematous, hypo- or hyperpigmented macules or patches that may have a slight scale - Pruritus may or may not be present • Lesions do not tan along w/ surrounding normal skin PITYRIASIS (TINEA) VERSICOLOR PITYRIASIS • Caused by lipophilic yeast Malassezia spp & M. furfur is the most common 2 DIAGNOSIS Microscopy • Potassium hydroxide (KOH) examination of skin scrapings should confi rm the diagnosis - Scales or debris are mounted in 10-15% KOH soln & viewed under light microscope - Short stubby hyphae & yeast cells will be visible (appears as “spaghetti & meatballs”) Culture • Culture is not usually helpful because Malassezia spp is diffi cult to grow as it is part of the normal fl ora Wood’s Light Exam • Malassezia spp shows pale yellow to white fl uorescence on Wood’s light exam Alternative Diagnosis • Other conditions w/ similar appearance as tinea versicolor include seborrheic dermatitis, secondary syphilis, & pityriasis alba A PATIENT EDUCATION • Educate patient about the basics of yeast growth - Causative agent is not eliminated from the skin & recurrence occurs in susceptible individuals - Malassezia spp are lipophilic; advise patient to avoid oils applied to the skin or in the bath Factors that Promote Tinea Versicolor Infection: • High temperature & high humidity - Prominent in tropical & subtropical regions • Occlusive clothing • Oily skin • Application of oils to skin • Excessive sweating • Immunocompromise conditions, malnutrition & hereditary predisposition • High levels of plasma cortisol B PHARMACOLOGICAL THERAPY • Condition chronically recurs in predisposed patients despite adequate initial treatment • Skin discoloration may take several wk to resolve after complete treatment Topical Antifungals • E ff e c t : Topical treatments are typically eff ective in temporarily eradicating the disease Selenium Sulfi de & Imidazoles • ese agents are equally eff ective w/ 60-80% recurrence rate Oral Antifungals • Oral therapy is indicated in cases of severe or widespread skin involvement, recurrent infections & failure of topical therapy • Oral therapy can be convenient & less time consuming enhancing patient compliance • Eff ect: Infection© recurrence may occur MIMSless frequently if treated w/ oral antifungals Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B191 © MIMS Pediatrics 2019 Pityriasis (Tinea) Versicolor (3 of 4) Dosage Guidelines ANTIFUNGALS (ORAL) Drug Dosage Remarks Fluconazole <2 wk: 3-6 mg/kg PO 72 hrly Adverse Reactions 2-4 wk: 3-6 mg/kg PO 48 hrly • GI eff ects (abdominal pain, N/V, diarrhea); Other PITYRIASIS (TINEA) VERSICOLOR PITYRIASIS >4 wk: 3-6 mg/kg PO 24 hrly eff ects (headache, insomnia, palpitations, pruritus, Max dose: 12 mg/kg/day sweating, fever, elevated serum transaminases) Itraconazole 100-200 mg PO 24 hrly x 5-7 days Adverse Reactions • GI eff ects (N/V, diarrhea, abdominal pain); Hepatic eff ects (elevation of serum transaminases, hepatitis & jaundice if treatment >1 mth); Other eff ects (headache, dizziness, pruritus, heart failure) Ketoconazole 15-30 kg: 100 mg PO 24 hrly Adverse Reactions >30 kg: 200 mg PO 24 hrly • GI eff ects (N/V, abdominal pain); Other eff ects (rashes, urticaria, itching, headache) • Rarely angioedema, paresthesia, thrombocytopenia, photophobia, dizziness, alopecia, gynecomastia, oligospermia, fatal liver damage - Risk of liver damage increases if given for >14 days ANTIFUNGALS (TOPICAL) Available Drug Strength Dosage Remarks Imidazoles Bifonazole 1% soln, cream Apply 24 hrly Adverse Reactions • Clotrimazole1 1% soln, lotn, Apply 8-12 hrly Occasional local irritation & cream, spray, hypersensitivity reactions, mild powd 2% cream burning, erythema & pruritus Special Instructions Econazole1 1% cream Apply 8-12 hrly • Treat for 2-3 wk unless otherwise stated Isoconazole 1% cream Apply 24 hrly Ketoconazole 2% gel, cream, Apply 12-24 hrly spray 1% scalp soln Apply & rinse off 24 hrly 2% soln,scalp x 5 days or soln Apply & rinse off twice wkly x 2-4 wk 2% shampoo Apply & rinse off after 3-5 min 24 hrly x 5 days 1Various strengths© & combinations w/ corticosteroids MIMS are available. Specifi c prescribing information may be found in the latest MIMS. All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Specifi c prescribing information may be found in the latest MIMS. B192 © MIMS Pediatrics 2019 Pityriasis (Tinea) Versicolor (4 of 4) Dosage Guidelines ANTIFUNGALS (TOPICAL) (CONT’D) Available Drug Strength Dosage Remarks Imidazoles (Cont’d) Miconazole 2% soln, tinct, Apply 12 hrly Adverse Reactions PITYRIASIS (TINEA) VERSICOLOR PITYRIASIS cream • Occasional local irritation & Sertaconazole 2% cream Apply 12-24 hrly hypersensitivity reactions, mild burning, erythema & pruritus Tioconazole 1% soln, cream, Apply 12-24 hrly Special Instructions lotn • Treat for 2-3 wk unless otherwise stated Other Antifungals Amorolfi ne 0.25% cream Apply 24 hrly x 2-3 wk Adverse Reactions • Erythema, pruritus, slight burning sensation Butenafi ne 1% cream Apply 24 hrly x 2-4 wk Adverse Reactions • Contact dermatitis, burning/ stinging sensation, erythema, irritation, itching Ciclopirox 1.5% liqd soap Apply & rinse after 3-5 min, Adverse Reactions ( Ciclopiroxolamine, 2-3x/wk • Pruritus, redness, burning, pain Ciclopirox olamine) Naftifi ne 1% cream Apply 24 hrly Adverse Reactions • Burning/stinging sensation, erythema, pruritus Salicylic acid1 3% bar, 4% tinct Apply 8-12 hrly Adverse Reactions • Skin irritation Selenium sulfi de 2.5% lotn, Apply & rinse off after Adverse Reactions shampoo, susp 5-10 min 24 hrly x 7 days • Occasionally local irritation, To prevent recurrence: hypersensitivity, mild burning, Apply & rinse off after erythema, pruritus 5-10 min once a mth Terbinafi ne 1% soln, cream, Apply 12 hrly x 1-2 wk Adverse Reactions gel, spray • Redness, stinging, itching, rarely allergic reactions Tolnaftate 1% soln, cream, Apply 8-12 hrly x 2-3 wk Adverse Reactions oint • Irritation, stinging, pruritus, contact dermatitis 1Various strengths & combinations of salicylic acid are available. Specifi c prescribing information may be found in the latest MIMS. All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. ©Not all products areMIMS available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Specifi c prescribing information may be found in the latest MIMS. Please see the end of this section for the reference list. B193 © MIMS Pediatrics 2019.