Pityriasis versicolor

The condition is most likely to be confused with vitiligo, but vitiligo is much more widespread over the body and usually includes the face. 

To prevent reinfection, ketoconazole shampoo should be used as above once a fortnight. 

A man in his mid-20s asks for something to clear up a skin condition that he has had for several months since returning from a holiday in Thailand. In response to your questions it emerges that the condition started with uneven, scaly patches on his upper chest where the skin didn t tan when he sunbathed. The patches have since spread to his entire back, chest and abdomen. He describes his skin as looking like a snake s and says he can scrape off the scales with his fingernail. The patches were not itchy to start with but are now. He saw his general practitioner about it and was prescribed an emollient cream that has not made any difference. Could you offer any advice  

Questions 1-3 concern the following topical fungal infections  

You receive the following FP10NC (England) prescription (WP10NC in Wales, GP10 in Scotland)  

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Oral treatment offers the advantage of bringing all the lesions at all sites under control, in addition to the absence of unpleasant cosmetic effects. In certain cases, it may be preferable to use oral treatment for C. albicans vaginitis and for extensive and persistent pityriasis versicolor, a skin disorder caused by Pityrosporum orbiculare. In the case of onychomycosis, a combination treatment, topical plus systemic, is required. It is preferable to use oral treatment for deep and systemic mycoses, though intravenous or intrathecal treatment is sometimes required. 

Miconazole is an imidazole antifungal agent used as miconazole base or miconazole nitrate for the treatment of superficial candidiasis and of skin infections dermato-phytosis and pityriasis versicolor. The drug has also been given intravenously by infusion for the treatment of disseminated fungal infections. Miconazole can be given by mouth in a dose of 120-240 mg, as oral gel four times daily after food, for... 

Selenium sulflde is a complementary drug for use in rare disorders or in exceptional circumstances. It has activity in pityriasis versicolor (lotion) and in se-borrhoeic dermatitis. Adverse effects include local irritation and hair discoloration or loss. Absorption may result in systemic toxicity including tremors, weakness, lethargy, pain in lower abdomen and occasional vomiting. 

Selenium sulfide is a cytostatic and sporicidal agent available without prescription in a variety of shampoos and lotions for treatment of scalp seborrheic dermatitis. Higher concentrations are available by prescription for the treatment of pityriasis versicolor, which is caused by the yeast M. furfur, and tinea capitis. 

It is indicated in vulvovaginal candidiasis. Trichomonas vaginitis, otomycosis, tinea and Pityriasis versicolor. 

Terbinafine is used in the treatment of dermatophytoses especially onchomycosis by oral therapy. Also useful in tinea and pityriasis versicolor. 

Topical and shampoo forms of ketoconazole are also available and useful in the treatment of seborrheic dermatitis and pityriasis versicolor. Several other azoles are available for topical use (see Preparations Available). 

There have been anecdotal reports of papular and non-papular rashes, pityriasis versicolor, hidradenitis suppurativa, and nail dystrophy (405,406), although causal relations are difficult to establish. 

Faergemann J Pityriasis versicolor Current treatments in Aly R, Beutner KR, Maibach H (eds) Cutaneous infection and therapy. New York, Dekker, 1997, pp 211—215. 

Miconazole is an alternative. Clotrimazole is an effective topical agent for dermatophyte, yeast, and other fungal infections (intertrigo, athlete s foot, ringworm, pityriasis versicolor, fungal nappy rash). 

Griseofulvin is effective against all superficial ringworm (dermatophyte) infections but is ineffective against pityriasis versicolor, superficial candidiasis and all systemic mycoses. 

Fungal infections superficial dermatophyte or Candida infections purely involving the skin can be treated with a topical imidazole (e.g. clotrimazole, miconazole). Pityriasis versicolor, a yeast infection, primarily involves the trunk m young adults it responds poorly to imidazoles but topical terbinafine or selenium sulphide preparations are effective severe infection may require systemic itraconazole. Invasion of hair or nails by a dermatophyte or a deep mycosis requires systemic therapy terbinafine is the most effective drug. Terbinafine and griseo-fulvin are ineffective against yeasts, for which itraconazole is an alternative. Itraconazole can be used in weekly pulses each month for 3-4 months it is less effective against dermatophytes than terbinafine. 

Captan is one of the older fungicides. It is used for pityriasis versicolor and is included in some soaps and cosmetics to provide bactericidal and fungicidal effects. It is allergenic. It is carcinogenic in mice, and in several countries control agencies have taken steps to prohibit its use in cosmetics and non-drug products (SEDA-13, 236). 

Selenium sulfide can cause local irritation (SED-12, 685). Photosensitive dermatitis (pityriasis versicolor) occurred in an adult man after a second application of 2.5% selenium sulfide (12). 

Pityriasis versicolor, a superficial skin infection caused by a yeast, Pityrosporum orbiculare (also known as Malassezzia furfur), can be treated with similar nonprescription preparations to fungal infections. 

Apply daily for pityriasis versicolor, until 2 weeks after the condition has cleared. (Date of prescribing and prescriber s signature)... 

The symptoms could describe pityriasis versicolor. Another possibility is vitiligo, but that is usually more widespread and also affects the face, there is no scaling and the skin does not itch. You could recommend an imidazole cream, e.g. clotrimazole, applied daily for 3 weeks. If the condition has not improved by then, he should go back to his doctor and ask to be referred to a dermatologist. 

Hyperpigmented and hypopigmented scaly patches characterize pityriasis versicolor. These patches are found on the trunk and... 

Pityriasis versicolor Clotrimazole, twice daily Econazole, daily Halprogin, twice daily Ketoconazole, daily Miconazole, twice daily Oxiconazole cream only, twice daily Sulconazole, twice daily Terbinafine, twice daily Tolnaftate, three times daily Ketoconazole 400 mg x 1 Eluconazole 400 mg x 1 Itraconazole 200 mg daily x 3-7 days... 

Gupta AK, Batra R, Bluhm R, Eaergemann J. Pityriasis versicolor. Dermatol Clin 2003 21 413 29. 

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