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Treatment of tinea versicolor with sulfur-salicylic shampoo
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Treatment of tinea versicolor with sulfur-salicylic shampoo Joel T. M. Bamford, M.D.
Duluth, MN One week of nightly application of sulfur-salicylic acid shampoo as a lotion was evaluated for the treatment of tinea versicolor. One half of the randomly allocated patients used the active preparation and the other half used a bland oil-in-water lotion as a placebo. Three months after completing treatment, nineteen of twenty-two using sulfur-salicylic acid shampoo were still negative by KOH examination, whereas only one of sixteen controls was negative. Skin irritation occurred in a few patients but did not reduce the effectiveness of the treatment. (J AM AcAo DERMATOL8:211-213, 1983.)
Although tinea versicolor can be treated successfully with several drugs, some of these agents have shortcomings which warranted trial of another preparation, Sodium thiosulfate is slow-acting and often ineffective. Tolnaftate requires prolonged use for widespread lesions. 1 Selenium sulfide (2.5%) shampoo is usually effective, 2-4 but there is concern for toxicity with prolonged treatment of large areas. 5 Sulfur and salicylic acid have been used as fungicides and occasionally for treatment of tinea versicolor. An easily available, safe, and cosmetically pleasant formulation was sought which would be effective in a simple regimen. The preparation chosen was 2% micropulverized sulfur and 2% salicylic acid in a shampoo base, sulfur-sal shampoo (Sebulex). In this study the active shampoo was applied as a lotion and cornpared to placebo, a bland oil-in-water lotion (Keri Lotion).
From the Department of Dermatology, University of Miami. Accepted for publication June 16, 1982. Address for reprints: 400 East Third St., Duluth, MN 55805.
0190-9622/83/020211+03500.30/0 © 1983 Am Acad Dermatol
Table I, Comparison of active and placebo groups Sulfur.sal
]
Placebo
shampoo (22) [ lotion (17)
Age 10-19 20-29 30-39 40-49 50-59 60 and over Average age White Black Female Male Duration of lesions Under 6 months Over 6 months Estimated extent (cm2) 10-50 50-200 20O+ Symptoms Yes No Prior treatment Yes No
4 3 4 7 2 2 37.5 19 3
4 4 3 3 3 0 32.8 15 2
14 8
11 6
2 20
4 13
5 i1 6
7 4 6
13 9
11 6
8 14
6 11 211
212
Journal of the American Academy of Dermatology
Bamford
Table II. Patient opinion, 3 weeks after completing treatment
I Sulfur-sal I Placebo shampoo lotion Improved 21 Same or worse 1 P (chi-square test) < 0.001%
6 I1
METHOD Forty-two subjects with clinical lesions volunteered for treatment using either placebo or active medication. All had typical microscopic spores and hyphal segments in KOH Scotch tape preparations, the method of Keddie et al. ~ Two volunteers were not accepted because they had recently used other topical treatments. After giving informed consent, forty subjects were assigned either to sulfur-sai shampoo (22) or placebo (18) using a table of random numbers. in each subject KOH-positive site was selected and marked on a patient diagram. Subsequent KOH preparations were made from the same site. A site was recorded as KOH-negative only after three separate preparations were found negative for hyphae or spores. During the first visit, subjects received medication and the following typed instructions: I. 2. 3. 4. 5.
Apply to affectedskin at bedtime Avoideyes and genital region Rinse off thoroughly in morning Repeatthis treatment nightly until you return in 1 week Bring ~,<~urmedication next week
At the first follow-up, the remaining medication was returned. Patients were checked at 3 weeks and 3 months after completing treatment. One control subject failed to return for any follow-up visits, making the placebo group seventeen. At 3 months the study was ended and, then, the code was broken. RESULTS The active and placebo groups are compared in Table I. They are similar in age, sex, duration, extent of involvement, symptoms, and prior treatment. Patient opinion at 3 weeks after completing treatment is given in Table II. Twenty-one of twenty-two subjects using sulfur-sal shampoo felt improved, while only six of the seventeen using placebo considered themselves improved.
The results of microscopic evaluation of K O H Scotch tape preparations are given in Table HI. At 3 months nineteen of twenty-two using sulfur-sal shampoo were still microscopically negative, compared with one microscopically negative among seventeen using the placebo. No adverse reactions were noted in the placebo group. In the active group, two w o m e n noted a burning sensation during the first application and rinsed off the medication. Both subjects completed the remaining six applications without recurrence of symptoms. Two other w o m e n applied the active shampoo for only six nights because the treated skin was becoming dry and slightly tender. However, all four subjects were K O H - n e g a t i v e at 3 months. In addition to the 3-month control study, the sulfur-sal shampoo group was evaluated again at 6 months. At that point, sixteen o f the original twenty-two subjects were still KOH-negative. These sixteen were considered " s u c c e s s e s . " The six "failures" at 6 months consisted of two KOH-positive at 3 weeks, one K O H - p o s i t i v e at 3 months, one KOH-positive at 6 m o n t h s , and two lost to follow-up at 6 months. In Table IV, the 6-month KOH results from this study are listed along with those reported by Allbright and Hitch) who used 2 . 5 % selenium sulfide shampoo overnight. In the latter study, only those subjects who became K O H - n e g a t i v e were followed for 6 months. CONCLUSION Micropulverized sulfur, 2%, and salicylic acid shampoo, 2%, applied as a lotion e v e r y night for 1 week, were effective as treatment for tinea versicolor. Skin irritation occurred in a f e w patients but did not reduce the effectiveness o f the treatment. Karen Elliott maintained the records. Iris M. Kiem, M.S., M.P.H., performed statistical analysis. David Taplin reviewed the article.
REFERENCES 1. Robinson HM Jr, Raskin J: Tolnaftate, a potent topical antifungal agent. Arch Dermatol 91:372-376, 1965. 2. Albright SD III, Hitch JM: Rapid treatment of tinea versicolor with selenium sulfide. Arch Dermatol 93:460-462, 1966.
Valume 8 Number 2 February, 1983
Treatment of tinea versicolor
213
T a b l e I I I . Fungi in K O H preparation, before and after treatment 3 weeks after
Before Placebo lotion
Suffur-sal shampoo
Placebo lotion
Sulfur-sal shampoo
Placebo
shampoo 22 0
17 0
2 20
16 1
3 19
i6 1
Sulfur-sal Positive Negative P (chi-square test)
<0.001
T a b l e IV. K O H preparation, 6 months after treatment
I Sulfur-salshampoo . . . . (present study) Positive Negative
[
6 16
3 months after
Selenium sulfide~ shampoo
lotion
<0.001
3, Levan NE: Selenium sulfide suspension in the treatment of tinea versicolor. Arch Dermatol 75:128-129, 1957. 4. Hersle K: Selenium sulfide treatment of tinea versicolor, Acta Derm Venereol (Stockh) 51:476-478, 1971. 5, Ransone JW, Scott NM Jr, Khobloek EC: Selenium sulfide intoxication. N Engl J Med 264:384-385, 1961, 6. Keddie F, Orr A, Liebes D: Direct staining on vinyl plastic tape demonstration of the cutaneous flora of the epidermis by the strip method, Sabouraudia 1:108-I1 I, 1961.
III
I
I I
I
Illlll
I
J
III
I I
II
III
II
II
I
Treatment of tinea versicolor with sulfur-salicylic shampoo Joel T. M. Bamford, M.D.
Duluth, MN One week of nightly application of sulfur-salicylic acid shampoo as a lotion was evaluated for the treatment of tinea versicolor. One half of the randomly allocated patients used the active preparation and the other half used a bland oil-in-water lotion as a placebo. Three months after completing treatment, nineteen of twenty-two using sulfur-salicylic acid shampoo were still negative by KOH examination, whereas only one of sixteen controls was negative. Skin irritation occurred in a few patients but did not reduce the effectiveness of the treatment. (J AM AcAo DERMATOL8:211-213, 1983.)
Although tinea versicolor can be treated successfully with several drugs, some of these agents have shortcomings which warranted trial of another preparation, Sodium thiosulfate is slow-acting and often ineffective. Tolnaftate requires prolonged use for widespread lesions. 1 Selenium sulfide (2.5%) shampoo is usually effective, 2-4 but there is concern for toxicity with prolonged treatment of large areas. 5 Sulfur and salicylic acid have been used as fungicides and occasionally for treatment of tinea versicolor. An easily available, safe, and cosmetically pleasant formulation was sought which would be effective in a simple regimen. The preparation chosen was 2% micropulverized sulfur and 2% salicylic acid in a shampoo base, sulfur-sal shampoo (Sebulex). In this study the active shampoo was applied as a lotion and cornpared to placebo, a bland oil-in-water lotion (Keri Lotion).
From the Department of Dermatology, University of Miami. Accepted for publication June 16, 1982. Address for reprints: 400 East Third St., Duluth, MN 55805.
0190-9622/83/020211+03500.30/0 © 1983 Am Acad Dermatol
Table I, Comparison of active and placebo groups Sulfur.sal
]
Placebo
shampoo (22) [ lotion (17)
Age 10-19 20-29 30-39 40-49 50-59 60 and over Average age White Black Female Male Duration of lesions Under 6 months Over 6 months Estimated extent (cm2) 10-50 50-200 20O+ Symptoms Yes No Prior treatment Yes No
4 3 4 7 2 2 37.5 19 3
4 4 3 3 3 0 32.8 15 2
14 8
11 6
2 20
4 13
5 i1 6
7 4 6
13 9
11 6
8 14
6 11 211
212
Journal of the American Academy of Dermatology
Bamford
Table II. Patient opinion, 3 weeks after completing treatment
I Sulfur-sal I Placebo shampoo lotion Improved 21 Same or worse 1 P (chi-square test) < 0.001%
6 I1
METHOD Forty-two subjects with clinical lesions volunteered for treatment using either placebo or active medication. All had typical microscopic spores and hyphal segments in KOH Scotch tape preparations, the method of Keddie et al. ~ Two volunteers were not accepted because they had recently used other topical treatments. After giving informed consent, forty subjects were assigned either to sulfur-sai shampoo (22) or placebo (18) using a table of random numbers. in each subject KOH-positive site was selected and marked on a patient diagram. Subsequent KOH preparations were made from the same site. A site was recorded as KOH-negative only after three separate preparations were found negative for hyphae or spores. During the first visit, subjects received medication and the following typed instructions: I. 2. 3. 4. 5.
Apply to affectedskin at bedtime Avoideyes and genital region Rinse off thoroughly in morning Repeatthis treatment nightly until you return in 1 week Bring ~,<~urmedication next week
At the first follow-up, the remaining medication was returned. Patients were checked at 3 weeks and 3 months after completing treatment. One control subject failed to return for any follow-up visits, making the placebo group seventeen. At 3 months the study was ended and, then, the code was broken. RESULTS The active and placebo groups are compared in Table I. They are similar in age, sex, duration, extent of involvement, symptoms, and prior treatment. Patient opinion at 3 weeks after completing treatment is given in Table II. Twenty-one of twenty-two subjects using sulfur-sal shampoo felt improved, while only six of the seventeen using placebo considered themselves improved.
The results of microscopic evaluation of K O H Scotch tape preparations are given in Table HI. At 3 months nineteen of twenty-two using sulfur-sal shampoo were still microscopically negative, compared with one microscopically negative among seventeen using the placebo. No adverse reactions were noted in the placebo group. In the active group, two w o m e n noted a burning sensation during the first application and rinsed off the medication. Both subjects completed the remaining six applications without recurrence of symptoms. Two other w o m e n applied the active shampoo for only six nights because the treated skin was becoming dry and slightly tender. However, all four subjects were K O H - n e g a t i v e at 3 months. In addition to the 3-month control study, the sulfur-sal shampoo group was evaluated again at 6 months. At that point, sixteen o f the original twenty-two subjects were still KOH-negative. These sixteen were considered " s u c c e s s e s . " The six "failures" at 6 months consisted of two KOH-positive at 3 weeks, one K O H - p o s i t i v e at 3 months, one KOH-positive at 6 m o n t h s , and two lost to follow-up at 6 months. In Table IV, the 6-month KOH results from this study are listed along with those reported by Allbright and Hitch) who used 2 . 5 % selenium sulfide shampoo overnight. In the latter study, only those subjects who became K O H - n e g a t i v e were followed for 6 months. CONCLUSION Micropulverized sulfur, 2%, and salicylic acid shampoo, 2%, applied as a lotion e v e r y night for 1 week, were effective as treatment for tinea versicolor. Skin irritation occurred in a f e w patients but did not reduce the effectiveness o f the treatment. Karen Elliott maintained the records. Iris M. Kiem, M.S., M.P.H., performed statistical analysis. David Taplin reviewed the article.
REFERENCES 1. Robinson HM Jr, Raskin J: Tolnaftate, a potent topical antifungal agent. Arch Dermatol 91:372-376, 1965. 2. Albright SD III, Hitch JM: Rapid treatment of tinea versicolor with selenium sulfide. Arch Dermatol 93:460-462, 1966.
Valume 8 Number 2 February, 1983
Treatment of tinea versicolor
213
T a b l e I I I . Fungi in K O H preparation, before and after treatment 3 weeks after
Before Placebo lotion
Suffur-sal shampoo
Placebo lotion
Sulfur-sal shampoo
Placebo
shampoo 22 0
17 0
2 20
16 1
3 19
i6 1
Sulfur-sal Positive Negative P (chi-square test)
<0.001
T a b l e IV. K O H preparation, 6 months after treatment
I Sulfur-salshampoo . . . . (present study) Positive Negative
[
6 16
3 months after
Selenium sulfide~ shampoo
lotion
<0.001
3, Levan NE: Selenium sulfide suspension in the treatment of tinea versicolor. Arch Dermatol 75:128-129, 1957. 4. Hersle K: Selenium sulfide treatment of tinea versicolor, Acta Derm Venereol (Stockh) 51:476-478, 1971. 5, Ransone JW, Scott NM Jr, Khobloek EC: Selenium sulfide intoxication. N Engl J Med 264:384-385, 1961, 6. Keddie F, Orr A, Liebes D: Direct staining on vinyl plastic tape demonstration of the cutaneous flora of the epidermis by the strip method, Sabouraudia 1:108-I1 I, 1961.