Tinea Versicolor

Introduction

Tinea Versicolor is caused by Malassezia furfur which is the mycelial phase of Pityrosporum orbiculare, a yeast which is a component of normal skin flora. It is slightly contagious but the disease is usually autogenous. It is common in young adults, uncommon in children and rare in old age. It affects both sexes equally. Systemic and topical steroid therapy predispose to this infection, as does Cushing's syndrome. Tinea Versicolor is a rather common infection of the superficial part of the skin caused by the yeast Malassezia furfur. Tinea Versicolor is most commonly seen in adolescents and young adults. The rash is more noticeable in the summer when the rest of the sun exposed skin is tanned but the skin affected by the rash does not tan.

What does TV look like?

Tinea Versicolor is usually seen as small and slowly enlarging scaly, white-to-tan spots scattered over the upper arms, chest, and back. The spots may appear on the neck, and face on some individuals. On light skin, the spots may not be recognized or they may show up as tan-to-pink spots. The fungal cells growing in large numbers on the skin prevent the skin from tanning normally; therefore, as the individual's skin tans in the sun, the spots become more noticeable. They appear as discreet white-to-pale-tan spots with a slightly scaly surface. The white patches are due to a bleaching agent produced by the yeast. When they occur on the exposed areas, such as the face and neck, their appearance may be very disturbing to the patient.

What are the symptoms of Tinea Versicolor?

Tinea Versicolor usually produces few, if any, symptoms. Occasionally, a patient will experience some slight itching. The scaling is minimal and develops as a very fine scale, usually when the patient rubs or scratches the area. Itching may be more intense when the patient is very hot. Who may become infected? The great majority of patients who develop Tinea Versicolor are teenagers or young adults. Tinea Versicolor is very rare in the elderly and is uncommon in children, except in tropical climates where it is seen in almost all ages. Individuals of both the dark and light skinned races seem to be equally susceptible. Some skin conditions, as determined at birth, may predispose a patient to Tinea Versicolor. For example, persons with oily skin may be more susceptible than those with naturally dry skin. Why do some people have Tinea Versicolor and others do not? The reasons why some individuals have Tinea Versicolor and others do not are not clearly understood. Since the fungus is normally present in small numbers on the skin, everyone could develop Tinea Versicolor. The yeast-like fungus usually grows slowly in the skin and normal hygiene removes the excess number of fungal cells along with the dead skin. During the summer months when the heat and humidity are high, the yeast cells increase in number and the removal of the skin scales is reduced; therefore, the fungus grows and forms small "colonies" on the surface of the skin. These colonies affect the normal pigmentation process, resulting in the light or dark colored spots. In some tropical countries where the heat and humidity are continuously high, persons have these spots year round. In temperate climates, Tinea Versicolor usually disappears in the cooler and drier months of the year.

How is this infection diagnosed in the office or laboratory?

Either the light or dark colored spots may resemble other skin conditions, but this infection is usually easily recognized in the office. In most cases, the signs and symptoms are sufficient to make an adequate diagnosis. In difficult cases, a simple, fast and economical direct examination of the fine scales scraped from the lesions will confirm the presence of the fungus. The patient's lesions are lightly scraped with a sterile blade onto a microscope slide. The preparation is moistened and observed under the microscope to identify the fungal cells. The positive findings are diagnostic for the disease and cultures need not be performed.

How is this fungal infection treated?

Tinea Versicolor is easily treated with either topical or oral medications, but the uneven pigmentation of the skin remains several months after the fungus has been eliminated. Many topical preparations act rapidly to eliminate the fungus from the skin. The preparations are applied directly to the skin, either once or twice a day. As mentioned earlier, recurrence of the rash is quite common. To prevent recurrence, special soaps containing Salicylic acid and Sulfur may be used. Those soaps must be used indefinitely.  They are: 2.5% Selenium Sulfide (Selsun or Exsel) Suspension and DHS Zinc Shampoo To treat tinea versicolor topically: First, apply DHS Zinc Shampoo to the affected areas. Leave on for five minutes, and then, wash off. At this point, apply 2.5% Selenium Sulfide (Selsun or Exsel) Suspension to the affected areas.  Allow the 2.5% Selenium Sulfide (Selsun or Exsel) Suspension to dry for 10 minutes, and then, wash off.  Repeat this process every day for 7 to fourteen consecutive days. If you need oral therapy: Orally, ketoconazole has been used successfully to eradicate the fungus in severe cases of tinea versicolor. Side effects with this medication discourage its use except in severe cases. Treatment is most effective when each patient is treated according to the severity of his or her disease, location of lesions, geographic area, climate, and the desire of the patient to have healthy-looking skin. Because the depigmentation is caused by a chemical agent. it is important to remember that the fungus is easy to kill, but it takes many weeks to repigment the skin. It's important to remember that the fungus is easy to kill, but it takes many weeks for the infected areas of the skin to regain their normal color. Treatment of this skin disease may take what seems to be a long time. Most treatments will remove Tinea Versicolor within several days, but to insure through treatment the medicine should be continued as prescribed for several weeks. It is possible for Tinea Versicolor to be gone, yet the bleaching agent remain for awhile. It is possible for Tinea Versicolor to recur. Some of the useful treatment options include: A. Selenium sulfide shampoo (ex. Selsun). B. Sodium Hyposulfite (ex. Tinver lotion) C. Antifungal agents (ex. miconazole)

A Word About Oral Medications

If your Tinea Versicolor is severe, Dr. Jacobs may discuss with you the possibility of using oral medications to treat your infection. There are three major oral medications used in the treatment of tinea versicolor: Nizoral Tablets (ketoconazole), Sporanox, Lamisil, and Diflucan Tablets. Though effective, there is no FDA approval on the use of these for tinea versicolor. As with any medical decision, one must always weigh risks and benefits when deciding on choosing a particular form of therapy. The oral medications do have possible side effects that you should be informed of. You should not use alcohol with these medications. You should inform Dr. Jacobs if you have any history of alcohol intake, liver disease, or any chronic diseases. All oral anti yeast medications are listed as being able to cause side effects involving allergies, death, changes in blood count, kidneys, and skin. Please ask your pharmacist for a list of possible side effects. Of note, Nizoral is known to cause liver toxicity and inflammation in 1 in 10,000 patients. This has been fatal in certain patients, even after taking the medication for a short time. To a lesser degree, Diflucan is also known to cause liver toxicity and inflammation. Diflucan has less reported side effects, but is extremely high in price. Sporanox has fewer side effects, but may have drug interactions, especially with Coumadin. If the benefits outweigh the risks in your condition, you may want to take an oral medication for your infection. If therapy is for greater than two weeks, or if there is a question of liver disease, Dr. Jacobs will order blood tests, initially, after two weeks, and then monthly for Nizoral, Sporanox, Lamisil, and Diflucan. If you have any further questions, please ask Dr. Jacobs at your next appointment. He will be happy to help you.