In pityriasis versicolor, an exceptionally abundant growth of yeast fungi normally present on the skin, or the patient's immune response, leads to visible skin changes.
This is usually a cosmetic problem. The disease is not contagious.
Pityriasis versicolor can recur after successful treatment.
Symptoms
On the trunk (photos F1F2F3), neck, proximal parts of the limbs there are very slightly scaly irregular patches.
The color of the patches varies from basic pale to reddish-brown, even "dirty" grey. On fair skin the patches are brown, on tanned skin they are lighter than the surrounding skin (photo F4).
Typical locations are the chest and upper back (high sweat rate areas), shoulders and sides of the trunk. It can also occur on the armpits, under the breasts, on the abdomen and in flexural areas.
Fairly common in young adults
It is not known why the normal skin colonizers, Malassezia yeasts, multiply to cause symptoms in some people. The disease is not transmitted from person to person.
After successful treatment, the disease may recur.
Investigations
The diagnosis is based on the clinical picture.
Usually no tests are needed.
Malassezia yeasts do not grow in normal fungal culture.
In microscopy of a sample scraped from a patch (e.g. methylene blue stained) typical Malassezia growth can be seen ("spaghetti and meatballs").
Ketoconazole shampoo (application once daily for 5 days; also a shorter treatment, even a single dose, may be sufficient). Before the summer season ketoconazole shampoo may used, as a prophylactic treatment, once daily for e.g. 3 days.
Zinc pyrithione shampoo 1%
Shampoos can be made more effective by leaving them on the scalp for 5 minutes before washing.
Adapalene or benzoyl peroxide gels may also help: once a day in the evening as a long-term treatment.
Systemic treatment
If systemic treatment is considered necessary in more severe cases, the most commonly used alternatives are.
itraconazole (e.g. 100 mg twice daily for 5-7 days) or
fluconazole (e.g. 300 mg once weekly for 2 weeks; other dosages have also been used, e.g. 150-300 mg once weekly for 1-3 weeks or 50 mg once daily for 2-4 weeks or 400 mg single dose).
Remember antifungal drug interactions with other drugs!
Even after effective treatment, it may take months for the skin to heal, especially in light-coloured patches, until it becomes tanned on exposure to sunlight.
Pityriasis versicolor recurs easily, and patients may need repeated treatments.
Topical treatments should be preferred for treating recurrences.
In more severe cases, systemic antifungal treatments have also been used in repeated courses, e.g. once every 3-6 months.
In recurrent pityriasis versicolor, preventive treatment has also been used, e.g. itraconazole 100 mg 2 capsules twice on one day per month (e.g. for 6 months). This is an off-label treatment but has been shown to be effective.
Pityriasis versicolor should not be handled as a contagious disease. Even its treatment is only a matter of controlling skin colonization.
Consultation
A dermatologist should be consulted, as necessary, in cases of treatment-resistant or diagnostically unclear clinical pictures.
References
Leung AK, Barankin B, Lam JM, et al. Tinea versicolor: an updated review. Drugs Context 2022;11(): [PubMed]
Saunte DML, Gaitanis G, Hay RJ. Malassezia-Associated Skin Diseases, the Use of Diagnostics and Treatment. Front Cell Infect Microbiol 2020;10():112 [PubMed]
Wang K, Cheng L, Li W, et al. Susceptibilities of Malassezia strains from pityriasis versicolor, Malassezia folliculitis and seborrheic dermatitis to antifungal drugs. Heliyon 2020;6(6):e04203 [PubMed]
Hald M, Arendrup MC, Svejgaard EL et al. Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. Acta Derm Venereol 2015;95(1):12-9. [PubMed]
Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg 2014;18(2):79-90. [PubMed]
Gupta AK, Lyons DC. Pityriasis versicolor: an update on pharmacological treatment options. Expert Opin Pharmacother 2014;15(12):1707-13. [PubMed]
Dehghan M, Akbari N, Alborzi N, et al. Single-dose oral fluconazole versus topical clotrimazole in patients with pityriasis versicolor: A double-blind randomized controlled trial. J Dermatol 2010;37(8):699-702 [PubMed]
Faergemann J, Gupta AK, Al Mofadi A, et al. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol 2002;138(1):69-73 [PubMed]
Lange DS, Richards HM, Guarnieri J et al. Ketoconazole 2% shampoo in the treatment of tinea versicolor: a multicenter, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol 1998;39(6):944-50. [PubMed]
Ximenes Mendes B, R Defante ML, de Moura de Souza M, et al. The role of topical adapalene as an add-on therapy for pityriasis versicolor: a pooled analysis of randomized controlled trials. Arch Dermatol Res 2025;317(1):264 [PubMed]