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Pityriasis Versicolor: Avoiding Pitfalls in Disease Diagnosis and Therapy
Pityriasis Versicolor: Avoiding Pitfalls in Disease Diagnosis and Therapy
Pityriasis Versicolor: Avoiding Pitfalls in Disease Diagnosis and Therapy
INTRODUCTION
The following case of pityriasis versicolor exemplifies the
importance of ruling out similar dermatologic conditions,
selecting an optimal treatment plan, and taking into account
special considerations military providers face. A 21-year-old,
otherwise healthy, active duty Marine Corps man was seen
in clinic for hypopigmented lesions on his back and neck,
initially appearing in 2009. Despite initiating a trial of overthe-counter topical terbinafine in 2011, his symptoms persisted
and became more bothersome by January 2012. The patient
was evaluated in the same clinic in July 2012, diagnosed with
tinea corporis, and prescribed 250 mg oral terbinafine daily for
30 days by a provider who moved soon after. Three months
later, the patient was seen with hypopigmented macules and
patches with very thin scaling when scraped (Fig. 1). The patient
was diagnosed with tinea versicolor (pityriasis versicolor1) and
prescribed 2% ketoconazole shampoo with instructions to use
the shampoo once daily for 3 consecutive days and follow up.
Upon re-evaluation, the patient reported no change, but on
examination the lesions did not show scale, suggesting a cure.
The patient was followed after a few months of continued
ketoconazole treatment. He reported an overall decrease in pruritic symptoms and was counseled that the hypopigmentation
might remain for several months.
To make the correct diagnosis of pityriasis versicolor, it is
important to distinguish between two other dermatologic
conditions: tinea corporis and pityriasis rosea.1 These three
conditions must be differentiated as they require different
treatments. Of note, additional differential diagnoses including vitiligo should be considered1,2; however, only the three
aforementioned diagnoses will be discussed further.
Pityriasis versicolor is a disease process that occurs when the
yeast, Malassezia (a component of normal skin flora), changes
to its hyphal form and causes pigmentary changes.2Keratinase
is also produced and causes loosening of the stratum corneum
and subsequent scale formation.3,4 The disease may present as
either hypopigmentation or hyperpigmentation. If tension is
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Pityriasis Versicolor
FIGURE 1.
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Pityriasis Versicolor
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REFERENCES
1. Kelly B: Superficial fungal infections. Pediatr Rev 2012; 33(4): e2237.
2. McNally B, McGraw T: Picture this. . . tinea versicolor. J Spec Oper
Med 2010; 10(1): 10710.
3. Han A, Calcara D, Stoecker WV, Daly J, Siegel DM, Shell A: Evoked
scale sign of tinea versicolor. Arch Dermatol 2009; 145(9): 1078.
4. Nevas J: Tinea versicolor: understanding effective treatment options.
Nurse Pract 2012: 37(1): 113.
5. Haisley-Royster C: Cutaneous infestations and infections. Adolesc Med
State Art Rev 2011; 22(1): 12945.
6. Mayser P, Rieche I: Rapid reversal of hyperpigmentation in pityriasis
versicolor upon short-term topical cycloserine application. Mycoses
2009; 52(6): 5413.
7. Petry V, Tanhausen F, Weiss L, Milan T, Mezzari A, Weber MB:
Identification of Malassezia yeast species isolated from patients with
pityriasis versicolor. An Bras Dermatol 2011; 86(4): 8036.
8. Shi TW, Ren XK: Roles of adapalene in the treatment of pityriasis
versicolor. Dermatology 2012; 224(2): 1848.
9. Wahab MA, Ali ME, Rahman MH, et al: Single dose (400mg) versus
7 day (200mg) daily dose itraconazole in the treatment of tinea versicolor:
a randomized clinical trial. Mymensingh Med J 2010; 19(1): 726.
10. Hu SW, Bigby M: Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010; 146(10): 113240.
11. Villars V, Jones TC: Clinical efficacy and tolerability of terbinafine
(Lamisil)a new topical and systemic fungicidal drug for treatment
of dermatomycoses. Clin Exp Dermatol 1989; 14(2): 1247.
12. Leeming JP, Sansom JE, Burton JL: Susceptibility of Malassezia furfur
subgroups to terbinafine. Br J Dermatol 1997; 137(5): 7647.
13. Cherniack EP: Bugs as drugs, Part 1: Insects: the new alternative
medicine for the 21st century? Altern Med Rev 2010; 15(2): 12435.
14. Stratman EJ: Failure to use available evidence to guide tinea versicolor
treatment: comment on pityriasis versicolor. Arch Dermatol 2010;
146(10): 1140.