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Guidelines of care for superficial mycotic infectionsof the skin: Pityriasis (tinea) versicolor
This report reflects the best data available at the time the report was prepared, but caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.
Guidelines of care for superficial mycotic infections of the skin: Pityriasis (tinea) versicolor Guidelines~Outcomes Committee: Lynn A. Drake, MD, Chairman, Scott M. Dinehart, MD, Evan R. Farmer, MD, Robert W. Goltz, MD, Gloria F. Graham, MD, Maria K. Hordinsky, MD, Charles W. Lewis, MD, David M. Pariser, MD, John W. Skouge, MD, Stephen B. Webster, MD, Duane C. Whitaker, MD, Barbara Butler, CPA-SDR Consultant, and Barbara J. Lowery, M P H Task Force: Boni E. Elewski, MD, Chairman, Mervyn L. Elgart, MD, Paul H. Jacobs, MD, Jack L. Lesher, Jr., MD, and Richard K. Scher, M D I. Introduction The American Academy of Dermatology's Guidelines/Outcomes Committee is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drag Administration. 11. Definition "Guidelines of Care for Superficial Mycotic Infections of the Skin: Pityriasis (Tinea) Versicolor" is one of six documents addressing superficial mycoses. Companion documents in this series include the following: Guidelines of Care for Superficial Mycotic Infections of the Skin: Mucocutaneous Candidiasis Guidelines of Care for Superficial Mycotic Infections of the Skin: .Tinea Corporis, Tinea Cruris, Tinea Faciei, Tinea Manuum, and Tinea Pedis Guidelines of Care for Superficial Mycotic Infections of the Skin: Tinea Capitis and Tinea Barbae Reprintrequests:AmericanAcademyofDermatology,P.O.Box4014, Schaumburg, IL 60168-4014.(Providedfree of charge) J AMACADD~ra~TOL1996;34:287-9. Copyright9 1996by the American Academyof Dermatology,Inc. 0190-9622/96$5.00+ 0 16/1/69828
Guidelines of Care for Superficial Mycotic Infections of the Skin: Onychomycosis Guidelines of Care for Superficial Mycotic Infections of the Skin: Piedra Pityriasis (tinea) versicolor is a superficial infection of the stratum comeum by the yeast Malassezia furfur (syn. Pityrosporum orbiculare). This yeast is part of the normal cutaneous flora. Pityriasis (tinea) versicolor is characterized by hyperpigrnented and hypopigmented scaly patches, primarily on the trunk and proximal extremities. III. Rationale A. Scope Pityriasis (tinea) versicolor is a common disorder that affects people of all age groups, but is most commonly seen in adults. Infants and children can also be affected, but often have an atypical presentation. This disease is typically worse in geographic areas with tropical ambient temperatures. Multiple factors are known to contribute to its pathogenesis. B. Issue Involvement of the cutaneous surface can occasionally be extensive, leading to emotional distress because of appearance. Symptoms vary from none to severe pruritus. Although numerous therapies are available, recurrences frequently occur after treatment, especially in tropical climates. IV. Diagnostic criteria A. Clinical 1. History may include the following: a. General medical condition, especially if
287
2,88 Drake et al. use of oral antifungals is considered, may include the following: t) Hepatic disease 2) Renal disease 3) Endocrine disease--diabetes mellitus 4) Use of systemic medications 5) Other b. Duration, progression to point of maximal severity c. Seasonal variation d. Current treatment(s), topical and systemic, of 1) Pityriasis versicolor 2) Other diseases e. Past treatment(s), topical and systemic, of 1) Pityriasis versicolor 2) Other diseases f. Other skin disorders, especially but not limited to the following: lj' Atopy, personal or familial (because of occasional irritation to topical antifungal agents) 2) Seborrheic dermalilis g. Drug allergies h. Habitual use of heavy oils on skin i. Other 2. Physical examination may include the following: a. General physical examination as indicated b. Location 1) Anterior aspect of the chest 2) Back 3) Extremities 4) Face, neck (more common in children) c. Clim'cal appearance 1) Hyperpigr~nted lesions 2) Hypopigmented lesions 3) Erythematons lesions d. Extent of involvement e. Gradation 1) Mild
2) Moderate 3) Severe f. Associated findings 1) Posfinflammatory hyperpigmentation and hypopigmentation 2) Pruritus 3) Excoriations 4) Other g. Other B. Diagnostic tests After review of the patient history and physical
Journal of the American Academy of Dermatology February 1996
examination, the diagnosis can often be established. Greater diagnostic accuracy occurs ff the clinical diagnosis is verified by laboratory tests. This verification is especially important when the use of systemic therapy is anticipated. Simple, inexpensive tests that can be performed in the physician's office at the time of the patient visit may yield immediate results. Such tests include, but are not limited to, the following: 1. Potassium hydroxide preparation (KOH) Scale from the affected area is placed on a glass slide, and 10% to 15% KOH is added with or without dimethyl sulfoxide (DMSO). If DMSO is included, gentle heating is generally not necessary. A fungal stain such as Chlorazol Black E, or Parker's blue-black ink may be added to highlight the hyphae and yeast cells. A confirmatory KOH preparation would reveal short, stubby hyphae and yeast cells. Patients may have a predominance of either. 2. Wood's light examination to demonstrate extent of involvement 3. Other stains Other stains may be used to identify the hyphae and yeast cells. These stains inchde, but are not limited to, the following: a. Paragon multiple stain b. Other 4. Studies for differential diagnosis may inelude the following: a. Fungal culture to exclude other mycoses M. furfur does not grow on roufine agars without growth supplements and is therefore not routinely cultured. b. Skin biopsy to differentiate pitydasis versicolor from other dermatoses c. Other 5. Other C. Inappropriate diagnostic tests Routine allergy testing D. Exceptions Not applicable E. Evolving diagnostic tests Not applicable V. Recommendations A. Treatment Topical treatment alone may be indicated for most patients. Systemic treatment may be indicated for persons with extensive involvement, with recunent infections, and in whom topical agents as sole therapy have failed. Systemic therapy may be used with or without topical agents or may be used alone in patients intolerant to topical treatment.
Journal of the American Academy of Dermatology Volume 34, Number 2, Part 1
1. Medical a. Topical antifungal products include, but are not limited to, the following: 1) Imidazoles 2) Ciclopirox olamine 3) Miscellaneous a) Selenium sulfide shampoos, lotions b) Zinc pyrithione shampoos c) Sulfur preparations d) Salicylic acid preparations e) Propylene glycol lotions f) Benzoyl peroxide g) Other 4) Other b. Systemic therapy (see V.A. above) 1) Ketoconazole 2) Evolving a) Fluconazole b) Itraconazole c) Other 3) Other 2. Surgical Not applicable 3. Other B. Miscellaneous 1. Follow-up Follow-up examinations may be indicated, depending on extent, severity, and tolerance to medications, as well as the need to augment or alternate treatment on the basis of clinical response. Intervals between visits will vary, depending on, but not limited to, the severity of the problem and the intensity of the treatment. 2. Monitoring of patients receiving systemic therapy Periodic monitoring of hepatic, renal, and hematopoietic function may be indicated in patients treated with systemic antifungals. 3. Drug interactions Oral antifungals have the potential for significant drug interactions and toxicities. The package insert and the Physician's DeskReferenee (PDR) should be consulted. 4. Contraindications and precautions for use of systemic antifungal therapy a. Hypersensitivity to medication b. Precautions (see package insert and the
PDR) c. Other VI. Supporting evidence See Bibliography (Appendix)
Drake et al. 289 VII. Disclaimer Adherence to these guidelines will not ensure successful treatment in every situation. Further, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgement regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. For the benefit of members of the American Academy of Dermatology who practice outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drug Administration. Appendix. Bibliography Albright SD, Hitch JM. Rapid treatmentof tinea versicolorwith a selenium sulfide shampoo. Arch Dermatol 1965;93:460-2. Bickers DR. Anfifimgaltherapy: potential interactions with other classes of drugs. J AM ACAI9DERMATOL1994;31;$87-90. Brodell RT, Elewski BE. ClinicalPearl: systemic antifungaldrugs and drug interactions. J AM ACADDERMATOL1995;33:259-60. DelescluseJ. Itraconazolein tinea versicolor,a review.J AMAo_Ao DERMATOL1990;23:551-4. FaergemannJ. Treatmentof pityfiasisversicolorwith itraconazole: a double-blind placebo-controlled study. Mycoses 1988;31: 377-9. Faergemann J, Djarv L. Tinea versicolor, treatment and prophylaxis with ketoconazole.Curls 1982;30:542-5, 550. Faergemann J, FredriekssonT. An open trial of the effect of a zinc pyrithioneshampoo in tinea versicolor.Curls 1980;25:667,669. Faergemann J, FredrikssonT. Propyleneglycol in the treatmentOf tinea versicolor. Acta Derm Venereol (Stockh) 1980;60:92-3. Gupta AK, SauderDN, Shear NH. Anfifungalagents: an overview. Part I. J AM ACADDERMATOL1994;30:677-98. Gupta AK, SauderDN, Shear NH. Antifungalagents: an overview. Part IL J AM AcADDF.RMATOL1994;30:911-33. Hay RJ. Antifungal drugs on the horizon. J AM ACADDERMATOL 1994;31:$82-5. Hay RJ, Midgeley G. Short course ketoconazoletherapy in pityriasis versicolor. Clin Exp Dermatol 1984;9:571-3. Hemgmdez-P6rezE. A comparison between one and two weeks' treatment with bifonazole in pityriasis versicolor. J AM ACAD DERMATOL1986;14:561-4. Lesher JL Jr, Smith JG Jr. Antifungalagents in dermatology.J AM ACADDERMATOL1987;17:383-94. Physicians' Desk Reference. Montrale, NJ: Medical Economics, 1995. Rausch LJ, JacobsPH. Tinea versicolor,treatmentand prophylaxis with monthly administration of ketoconazole. Cuffs 1984; 34:470-1. Savin RC, Horwitz SN. Double-blindcomparisonof 2% ketoeonazole cream and placebo in the treatment of tinea versicolor.J AM ACAODERMATOL1986;15:500-3. Svejgaard E. Double-blindtrial of miconazolein dermatomycosis. Acta Derm Venereol (Stockh) 1973;53:497-500. Zaias N. Pityriasisversicolorwith ketoconazole.J AM ACADDERMATOL1989;20:703-4.
Guidelines of care for superficial mycotic infections of the skin: Pityriasis (tinea) versicolor Guidelines~Outcomes Committee: Lynn A. Drake, MD, Chairman, Scott M. Dinehart, MD, Evan R. Farmer, MD, Robert W. Goltz, MD, Gloria F. Graham, MD, Maria K. Hordinsky, MD, Charles W. Lewis, MD, David M. Pariser, MD, John W. Skouge, MD, Stephen B. Webster, MD, Duane C. Whitaker, MD, Barbara Butler, CPA-SDR Consultant, and Barbara J. Lowery, M P H Task Force: Boni E. Elewski, MD, Chairman, Mervyn L. Elgart, MD, Paul H. Jacobs, MD, Jack L. Lesher, Jr., MD, and Richard K. Scher, M D I. Introduction The American Academy of Dermatology's Guidelines/Outcomes Committee is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drag Administration. 11. Definition "Guidelines of Care for Superficial Mycotic Infections of the Skin: Pityriasis (Tinea) Versicolor" is one of six documents addressing superficial mycoses. Companion documents in this series include the following: Guidelines of Care for Superficial Mycotic Infections of the Skin: Mucocutaneous Candidiasis Guidelines of Care for Superficial Mycotic Infections of the Skin: .Tinea Corporis, Tinea Cruris, Tinea Faciei, Tinea Manuum, and Tinea Pedis Guidelines of Care for Superficial Mycotic Infections of the Skin: Tinea Capitis and Tinea Barbae Reprintrequests:AmericanAcademyofDermatology,P.O.Box4014, Schaumburg, IL 60168-4014.(Providedfree of charge) J AMACADD~ra~TOL1996;34:287-9. Copyright9 1996by the American Academyof Dermatology,Inc. 0190-9622/96$5.00+ 0 16/1/69828
Guidelines of Care for Superficial Mycotic Infections of the Skin: Onychomycosis Guidelines of Care for Superficial Mycotic Infections of the Skin: Piedra Pityriasis (tinea) versicolor is a superficial infection of the stratum comeum by the yeast Malassezia furfur (syn. Pityrosporum orbiculare). This yeast is part of the normal cutaneous flora. Pityriasis (tinea) versicolor is characterized by hyperpigrnented and hypopigmented scaly patches, primarily on the trunk and proximal extremities. III. Rationale A. Scope Pityriasis (tinea) versicolor is a common disorder that affects people of all age groups, but is most commonly seen in adults. Infants and children can also be affected, but often have an atypical presentation. This disease is typically worse in geographic areas with tropical ambient temperatures. Multiple factors are known to contribute to its pathogenesis. B. Issue Involvement of the cutaneous surface can occasionally be extensive, leading to emotional distress because of appearance. Symptoms vary from none to severe pruritus. Although numerous therapies are available, recurrences frequently occur after treatment, especially in tropical climates. IV. Diagnostic criteria A. Clinical 1. History may include the following: a. General medical condition, especially if
287
2,88 Drake et al. use of oral antifungals is considered, may include the following: t) Hepatic disease 2) Renal disease 3) Endocrine disease--diabetes mellitus 4) Use of systemic medications 5) Other b. Duration, progression to point of maximal severity c. Seasonal variation d. Current treatment(s), topical and systemic, of 1) Pityriasis versicolor 2) Other diseases e. Past treatment(s), topical and systemic, of 1) Pityriasis versicolor 2) Other diseases f. Other skin disorders, especially but not limited to the following: lj' Atopy, personal or familial (because of occasional irritation to topical antifungal agents) 2) Seborrheic dermalilis g. Drug allergies h. Habitual use of heavy oils on skin i. Other 2. Physical examination may include the following: a. General physical examination as indicated b. Location 1) Anterior aspect of the chest 2) Back 3) Extremities 4) Face, neck (more common in children) c. Clim'cal appearance 1) Hyperpigr~nted lesions 2) Hypopigmented lesions 3) Erythematons lesions d. Extent of involvement e. Gradation 1) Mild
2) Moderate 3) Severe f. Associated findings 1) Posfinflammatory hyperpigmentation and hypopigmentation 2) Pruritus 3) Excoriations 4) Other g. Other B. Diagnostic tests After review of the patient history and physical
Journal of the American Academy of Dermatology February 1996
examination, the diagnosis can often be established. Greater diagnostic accuracy occurs ff the clinical diagnosis is verified by laboratory tests. This verification is especially important when the use of systemic therapy is anticipated. Simple, inexpensive tests that can be performed in the physician's office at the time of the patient visit may yield immediate results. Such tests include, but are not limited to, the following: 1. Potassium hydroxide preparation (KOH) Scale from the affected area is placed on a glass slide, and 10% to 15% KOH is added with or without dimethyl sulfoxide (DMSO). If DMSO is included, gentle heating is generally not necessary. A fungal stain such as Chlorazol Black E, or Parker's blue-black ink may be added to highlight the hyphae and yeast cells. A confirmatory KOH preparation would reveal short, stubby hyphae and yeast cells. Patients may have a predominance of either. 2. Wood's light examination to demonstrate extent of involvement 3. Other stains Other stains may be used to identify the hyphae and yeast cells. These stains inchde, but are not limited to, the following: a. Paragon multiple stain b. Other 4. Studies for differential diagnosis may inelude the following: a. Fungal culture to exclude other mycoses M. furfur does not grow on roufine agars without growth supplements and is therefore not routinely cultured. b. Skin biopsy to differentiate pitydasis versicolor from other dermatoses c. Other 5. Other C. Inappropriate diagnostic tests Routine allergy testing D. Exceptions Not applicable E. Evolving diagnostic tests Not applicable V. Recommendations A. Treatment Topical treatment alone may be indicated for most patients. Systemic treatment may be indicated for persons with extensive involvement, with recunent infections, and in whom topical agents as sole therapy have failed. Systemic therapy may be used with or without topical agents or may be used alone in patients intolerant to topical treatment.
Journal of the American Academy of Dermatology Volume 34, Number 2, Part 1
1. Medical a. Topical antifungal products include, but are not limited to, the following: 1) Imidazoles 2) Ciclopirox olamine 3) Miscellaneous a) Selenium sulfide shampoos, lotions b) Zinc pyrithione shampoos c) Sulfur preparations d) Salicylic acid preparations e) Propylene glycol lotions f) Benzoyl peroxide g) Other 4) Other b. Systemic therapy (see V.A. above) 1) Ketoconazole 2) Evolving a) Fluconazole b) Itraconazole c) Other 3) Other 2. Surgical Not applicable 3. Other B. Miscellaneous 1. Follow-up Follow-up examinations may be indicated, depending on extent, severity, and tolerance to medications, as well as the need to augment or alternate treatment on the basis of clinical response. Intervals between visits will vary, depending on, but not limited to, the severity of the problem and the intensity of the treatment. 2. Monitoring of patients receiving systemic therapy Periodic monitoring of hepatic, renal, and hematopoietic function may be indicated in patients treated with systemic antifungals. 3. Drug interactions Oral antifungals have the potential for significant drug interactions and toxicities. The package insert and the Physician's DeskReferenee (PDR) should be consulted. 4. Contraindications and precautions for use of systemic antifungal therapy a. Hypersensitivity to medication b. Precautions (see package insert and the
PDR) c. Other VI. Supporting evidence See Bibliography (Appendix)
Drake et al. 289 VII. Disclaimer Adherence to these guidelines will not ensure successful treatment in every situation. Further, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgement regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. For the benefit of members of the American Academy of Dermatology who practice outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drug Administration. Appendix. Bibliography Albright SD, Hitch JM. Rapid treatmentof tinea versicolorwith a selenium sulfide shampoo. Arch Dermatol 1965;93:460-2. Bickers DR. Anfifimgaltherapy: potential interactions with other classes of drugs. J AM ACAI9DERMATOL1994;31;$87-90. Brodell RT, Elewski BE. ClinicalPearl: systemic antifungaldrugs and drug interactions. J AM ACADDERMATOL1995;33:259-60. DelescluseJ. Itraconazolein tinea versicolor,a review.J AMAo_Ao DERMATOL1990;23:551-4. FaergemannJ. Treatmentof pityfiasisversicolorwith itraconazole: a double-blind placebo-controlled study. Mycoses 1988;31: 377-9. Faergemann J, Djarv L. Tinea versicolor, treatment and prophylaxis with ketoconazole.Curls 1982;30:542-5, 550. Faergemann J, FredriekssonT. An open trial of the effect of a zinc pyrithioneshampoo in tinea versicolor.Curls 1980;25:667,669. Faergemann J, FredrikssonT. Propyleneglycol in the treatmentOf tinea versicolor. Acta Derm Venereol (Stockh) 1980;60:92-3. Gupta AK, SauderDN, Shear NH. Anfifungalagents: an overview. Part I. J AM ACADDERMATOL1994;30:677-98. Gupta AK, SauderDN, Shear NH. Antifungalagents: an overview. Part IL J AM AcADDF.RMATOL1994;30:911-33. Hay RJ. Antifungal drugs on the horizon. J AM ACADDERMATOL 1994;31:$82-5. Hay RJ, Midgeley G. Short course ketoconazoletherapy in pityriasis versicolor. Clin Exp Dermatol 1984;9:571-3. Hemgmdez-P6rezE. A comparison between one and two weeks' treatment with bifonazole in pityriasis versicolor. J AM ACAD DERMATOL1986;14:561-4. Lesher JL Jr, Smith JG Jr. Antifungalagents in dermatology.J AM ACADDERMATOL1987;17:383-94. Physicians' Desk Reference. Montrale, NJ: Medical Economics, 1995. Rausch LJ, JacobsPH. Tinea versicolor,treatmentand prophylaxis with monthly administration of ketoconazole. Cuffs 1984; 34:470-1. Savin RC, Horwitz SN. Double-blindcomparisonof 2% ketoeonazole cream and placebo in the treatment of tinea versicolor.J AM ACAODERMATOL1986;15:500-3. Svejgaard E. Double-blindtrial of miconazolein dermatomycosis. Acta Derm Venereol (Stockh) 1973;53:497-500. Zaias N. Pityriasisversicolorwith ketoconazole.J AM ACADDERMATOL1989;20:703-4.