Tinea versicolor is a misnomer because it is not actually a tinea or dermatophyte. The name pityriasis is more appropriate for this infection, which is caused by Malassezia furfur. Versicolor presents as hypopigmented macules (sometimes hyperpigmented) scattered on the shoulders, upper back, and chest. The macules may be pink, red, light-brown, or white and have a slight scale, which may only be seen after scratching.

The hypopigmentation may only be noted after sun exposure. The macules are sometimes mistaken for vitiligo, but vitiligo is characterized by a complete loss of pigment. Versicolor will fluoresce a gold or orange-brown color under a Wood lamp. KOH preparation of scales reveals non-branching hyphae and clusters of round spores, described as the “spaghetti-and-meatballs” pattern.

Pityriasis versicolor responds well to topical therapy with dandruff shampoos containing selenium sulfide (Selsun) or pyrithione zinc (Head & Shoulders). A lather should be applied to the affected skin and left to sit for 10 minutes daily for 1 week. Ketoconazole shampoo is another option that can be used twice weekly for 4 weeks. Topical antifungal agents are also recommended by some practitioners.

Widespread or persistent cases can be treated with oral ketoconazole. Ketoconazole can be given as 200 mg daily for 7 to 10 days. Another option is 400 mg ketoconazole once, and some practitioners consider this the treatment of choice. This should be followed by exercise to induce sweating, and the patient should wait 1 day before showering. This should be repeated in 1 week. Other oral regimens include fluconazole 300 to 400 mg once or itraconazole 400 g daily for 3 to 7 days.

The discoloration of pityriasis versicolor does not resolve immediately following treatment. Normal pigmentation will not return until the skin is exposed to sunlight. Response to treatment is presumed when the scales disappear.

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