Incidence

1. Tinea versicolor is seen most frequently in adolescents and young adults.

Pathogenesis

1. Tinea versicolor is a fungal infection of the skin caused by an overgrowth of Malassezia (formerly known as the Pityrosporum orbiculare), part of the normal skin flora.
2. Discoloration of the skin is seen, forming round or oval maculae, which may become confluent.
3. Maculae range from 1 cm to very large, greater than 30 cm.

Predisposing Factors

1. Immunosuppressive therapy.
2. Pregnancy.
3. Warm temperatures.
4. Corticosteroid therapy.

Common Complaints

1. Scaly rash on the upper trunk with occasional mild itching.

Other Signs and Symptoms

1. Annular maculae with mild scaling.
2. Asymptomatic or pruritic.
3. Pink-, white-, or brown-colored rash.

Subjective Data

1. Ascertain when and where the rash began.
2. Have the patient describe how the rash has changed.
3. Assess the patient for any associated symptoms with the rash, such as itching and burning.
4. Identify what products the patient has used on the skin to treat rash and with what results.
5. Elicit information regarding a history of similar rashes.
6. Query the patient regarding current medications.
7. Review any medical history for comorbid conditions.

Physical Examination

1. Inspect:
   1. Inspect skin and note type of lesion.
   2. Examine other areas of skin for similar lesions.

Diagnostic Tests

1. Wet prep/potassium hydroxide (KOH).
2. Wood’s lamp: Wood’s light is useful in examining skin to determine the extent of infection. Inspection of fine scales with Wood’s lamp reveals scales with a pale yellow-green fluorescence that contain the fungus.
3. Culture lesion: When obtaining a sample scraping, obtain sample from edge of lesion for best sample of hyphae. (Hyphae and spores have a “spaghetti and meatball” appearance.)

Differential Diagnoses

1. Tinea versicolor.
2. Tinea corporis.
3. Pityriasis alba.
4. Pityriasis rosea: Herald patch is clue to diagnosis.
5. Seborrheic dermatitis.
6. Vitiligo.

Plan

1. General interventions: Apply medication as directed.
2. See Section III: Patient Teaching Guide “Tinea Versicolor.”
   1. Because causative species is a normal inhabitant of skin flora, recurrence is possible.
   2. Skin pigmentation returns after infection is cleared up. This may take several months to resolve.
3. Pharmaceutical therapy:
   1. Selenium sulfide 2.5% (Selsun Blue):
      1. Advise patient to shower at bedtime. Then apply selenium sulfide 2.5% cream to skin, covering entire body from chin down to toes. Leave treatment on skin for 8 to 10 hours. Shower off in the morning.
      2. A second treatment option includes applying the selenium sulfide 2.5% cream to skin lesions daily for 12 days. Leave treatment on skin for 30 minutes, then shower off.
      3. Treatment may be needed monthly until desired results are obtained. Encourage use of Selsun Blue on entire body surface except for face and head.
   2. Other medications used:
      1. Clotrimazole 1% cream twice daily for 4 weeks.
      2. Ketoconazole (Nizoral) cream daily for 14 days.
      3. Fluconazole 300 mg once weekly for 2 weeks. When using fluconazole as treatment, caution the patient regarding liver damage with toxicity.

Follow-Up

1. None is required if resolution occurs.
2. Monitor liver function tests (LFTs) every 6 weeks if patient is on ketoconazole.

Consultation/Referral

1. Consult with a physician if current treatment is unsuccessful.

Individual Considerations

1. Adults: Commonly seen in young adults and rare with geriatric population.