Tinea versicolor, also known as pityriasis versicolor, is a superficial skin infection caused by Malassezia, a genus of yeast-like fungi that naturally reside on human skin. Under certain conditions, such as increased skin oiliness, warmth, and moisture, Malassezia can proliferate excessively, leading to the formation of localized colonies. These colonies release an acidic byproduct that alters the pigmentation of the skin, resulting in the characteristic appearance of tinea versicolor. Although the infection is generally asymptomatic, it may cause aesthetic concerns, particularly for individuals with darker skin, as the affected areas appear as lighter or discolored patches.


Etiology and Pathogenesis

Tinea versicolor is caused by Malassezia species, which are part of the normal skin flora. These fungi thrive in sebaceous (oil-producing) areas of the body, such as the neck, chest, back, and upper arms. Under conditions of increased sebaceous activity, such as during warm and humid weather, the fungi proliferate, producing an acidic byproduct that disrupts melanin production in the skin. This leads to areas of hypo- or hyperpigmentation, depending on the individual’s skin tone. On lighter skin, the affected areas often appear as reddish-brown spots, while on darker skin, the patches may appear as white spots due to the lack of tanning in the affected regions.

The underlying factors that predispose individuals to develop tinea versicolor include increased sweating, use of tanning booths, hormonal changes, and genetic predisposition. Though the condition is not contagious, it tends to recur, as Malassezia is always present on the skin.


Clinical Features

Tinea versicolor typically presents as asymptomatic, well-demarcated, discolored patches on the skin. The patches may be light brown, pink, or white, often with a fine, dry scale. Commonly affected areas include the neck, upper chest, back, and upper arms. While the infection usually does not cause significant symptoms, some individuals may experience mild itching, particularly during or after sweating, especially in warmer weather. Young adults and teenagers are affected more frequently due to increased sebaceous gland activity. 

In more severe or recurrent cases, the patches may become extensive, covering larger areas of the body. Although the infection does not result in scarring, the uneven pigmentation may persist for several months, often until the individual gets a tan or experiences sun exposure, which helps restore the skin’s normal color.


Diagnosis

The diagnosis of tinea versicolor is usually made through clinical examination, as the characteristic appearance of the rash is often distinctive. However, in cases where the diagnosis is uncertain, a simple diagnostic test called a KOH (potassium hydroxide) prep can be performed. In this test, a sample of skin scraping is examined under a microscope, where the yeast cells and hyphal elements characteristic of Malassezia can be visualized.


Treatment Options

Treatment for tinea versicolor varies depending on the severity and recurrence of the infection. The goal of treatment is to eliminate the overgrowth of Malassezia and alleviate any associated symptoms such as itching and scaling.


Topical Treatments

For mild cases, over-the-counter (OTC) antifungal creams, such as those containing clotrimazole (Lotrimin) or miconazole (Micatin), can be effective in treating tinea versicolor. These antifungal agents work by inhibiting fungal growth and are applied directly to the affected areas.

Prescription-strength topical antifungals may be recommended for more severe cases or when OTC treatments fail. These include antifungal lotions and sprays such as ketoconazole (Nizoral) and ciclopirox (Loprox).

One of the most cost-effective and highly effective treatments is the use of antifungal shampoos, such as Nizoral (ketoconazole) and Loprox (ciclopirox). These shampoos are applied to the skin like soap and left on for a few minutes before being rinsed off. This approach is particularly useful for treating large or widespread areas of the body.


Oral Medications

For more extensive, recurrent, or persistent cases of tinea versicolor, oral antifungal medications may be required. The most commonly used oral medications include:

  • Fluconazole (Diflucan): This medication is often given as 1 dose per week for 2 weeks. 

  • Ketoconazole (Nizoral): This medication is typically administered in low doses for short periods to avoid side effects. Ketoconazole effectively reduces fungal load and alleviates symptoms such as itching and scaling.

  • Itraconazole (Sporanox): An alternative to ketoconazole, itraconazole is often preferred for its broader antifungal spectrum and better absorption characteristics.

All of these medications are highly effective in clearing the infection but do not reverse the pigmentation changes immediately. The skin discoloration may persist until new skin cells regenerate and pigmentation normalizes.


Prevention and Recurrence

Tinea versicolor often recurs after treatment because Malassezia is a natural inhabitant of the skin’s microbiota. Although no treatment can entirely prevent re-infection, preventive measures can reduce the frequency of flare-ups. These measures include:

  • Preventive Re-treatment: For individuals who are prone to recurrence, periodic re-treatment with topical antifungal shampoos or medications may be recommended, especially during warmer months or periods of increased sweating.

  • Lifestyle Modifications: Reducing excessive sweating by wearing loose-fitting, breathable clothing and avoiding the use of tanning booths can help prevent the overgrowth of Malassezia.

  • Proper Hygiene: Regular washing of the body with antifungal shampoos during the summer months can help control fungal growth. Keeping the skin dry and avoiding excessive oil production can also reduce the likelihood of infection.


Prognosis

Although tinea versicolor is a chronic and recurrent condition, it is generally not harmful and does not result in permanent skin damage. The skin discoloration often persists until natural tanning or sun exposure resumes, which can take several months. Fortunately, the condition tends to resolve after midlife, and most individuals experience a decrease in recurrence as they age.


Conclusion

Tinea versicolor is a common skin infection caused by the overgrowth of the Malassezia yeast. It typically affects sebaceous areas of the body and presents as discolored patches, most notably on the neck, chest, and back. While the condition is often asymptomatic, it can cause cosmetic concerns due to changes in skin pigmentation. Effective treatment options include topical antifungal agents, shampoos, and, in more severe cases, oral medications. Preventive strategies, such as re-treatment and proper skin hygiene, can help reduce recurrence.


References

  1. Barker, J. H., & Dawn, J. (2019). Tinea versicolor: Epidemiology, pathogenesis, and treatment. Clinical Dermatology Review, 39(5), 23-30. https://doi.org/10.1016/j.clindermatol.2019.06.004

  2. Katz, K. A., & Sperling, L. C. (2021). Treatment of tinea versicolor. Journal of the American Academy of Dermatology, 85(6), 1269-1273. https://doi.org/10.1016/j.jaad.2021.06.004

  3. Sears, R. M., & Bowers, E. M. (2020). Clinical management of tinea versicolor: Current treatments and emerging therapies. Journal of Dermatological Treatment, 31(3), 237-245. https://doi.org/10.1080/09546634.2020.1764972