List of Abbreviations
HIV – human immunodeficiency virus
Terms and Definitions
Pityriasis versicolor (tinea versicolor, pityriasis versicolor, tinea versicolor) is a chronic superficial fungal skin infection caused by the proliferation of lipophilic yeasts (Malassezia Species) in the stratum corneum of the epidermis.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Pityriasis versicolor (tinea versicolor, pityriasis versicolor, tinea versicolor) is a chronic superficial fungal skin infection caused by the proliferation of lipophilic yeasts (Malassezia Species) in the stratum corneum of the epidermis.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The causative agents of pityriasis versicolor are dimorphic lipophilic yeasts of the genus Malassezia, which are members of the normal skin microflora. Malassezia globosa, M. sympodialis, and M. furfur are most commonly detected, while M. slooffiae, M. restricta, and M. obtusa are rarer. It has been established that about 90% of healthy people are carriers of the saprophytic form of the fungus.
Under the influence of endogenous predisposing factors (hyperhidrosis, changes in sweat chemical composition, decreased physiological desquamation of the epidermis, familial susceptibility, immunosuppression) and/or exogenous factors (humidity and high temperature), the pathogen transforms from a non-pathogenic budding blastospore into a pathogenic mycelial form. The latter is capable of synthesizing an enzyme that inhibits the production of light-absorbing pigment, or toxic compounds that destroy pigment-producing cells [1]. The pathogen exhibits a tropism for skin areas with a high density of sebaceous glands. Immune factors may be involved in the pathogenesis, but they are difficult to interpret. Patients with pityriasis versicolor do not have cell-mediated immunodeficiency to mycelial antigens of Malassezia spp.
1.3 Epidemiology of the Disease or Condition
Pityriasis versicolor mainly affects adolescents and young adults aged 10 to 30 years, but can occur in individuals of any age category, including infants and the elderly. It is more frequently reported in populations living in regions with hot and humid climates. There is no convincing evidence that sex or any particular ethnic group is more susceptible [2].
The contagiousness of the disease is low. It more frequently develops in individuals with concomitant endocrine disorders, chronic pulmonary and gastrointestinal diseases, autonomic-vascular disorders, immunodeficiencies of various origins, etc. Tinea versicolor is classified as an HIV-associated condition. A genetic (multifactorial) predisposition is also possible. The probability of developing the disease in 1st- and 2nd-degree relatives is 22–48% [3]. Triggering factors may include nutritional deficiency, systemic hormonal contraceptives, systemic corticosteroids, corticosteroids used in dermatology, immunosuppressants, as well as hyperhidrosis and the use of oil- or grease-based skincare products.
1.4 Features of Coding the Disease or Condition
Other superficial mycoses (B36):
B36.0 – Tinea versicolor.
1.5 Classification of the disease or condition
None.
1.6 Clinical presentation of the disease or condition
Tinea versicolor generally runs without subjective sensations; some patients experience mild pruritus. The primary concern for patients seeking medical attention is the unpleasant cosmetic appearance of the skin, although altered pigmentation may persist after treatment.
The rashes are most frequently localized on the skin of the chest, upper back, shoulders, posterior neck; the scalp and penis may also be involved. Atypical localizations of tinea versicolor include: the face, auricles, retroauricular folds, hands, shins, inguinal and axillary regions, as well as the nipple and periareolar area. In children, the disease often begins on the scalp, but the hair is not affected. Tinea versicolor is not observed on the palms, soles, or mucous membranes.
Initially, the disease is characterized by the appearance of poorly demarcated light or dark spots, 3 to 5 mm in diameter, round or oval in shape, without inflammatory phenomena. The color of the spots varies (hence the name "versicolor") from pink to brown. The spots are often multiple and may coalesce to form large foci with polycyclic contours. Sometimes, upon examination of large foci, a slight pseudoatrophy can be detected in their center. As a result of central involution, the foci may acquire an annular shape.
Upon scratching the surface of the spots, fine lamellar scales are detected (the latent desquamation sign, or Besnier-Meshchersky sign), resembling bran (pityriasis versicolor). Following sun exposure, due to increased desquamation in the affected areas, depigmented skin patches remain. Rashes often appear hyperpigmented on lighter skin types and hypopigmented on dark or tanned skin.
A special form of the disease is distinguished – tinea versicolor alba, or white pityriasis. In this case, complete depigmentation may occur in the absence of any desquamation. Depigmentation here is not directly related to the shielding properties of the fungal colonies and can occur on areas of the skin that have not been exposed to solar radiation.
Symptoms may worsen in hot weather. Patients with tinea versicolor often seek medical attention at the depigmented spot stage.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition:
The diagnosis of tinea versicolor is established based on the results of:
1) analysis of anamnestic data
2) physical examination, taking into account the clinical presentation and the results of the iodine test
3) laboratory tests (microscopic examination of skin scrapings for fungi (yeasts, molds, dermatophytes)),
4) instrumental examination (luminescence diagnostics (examination under a Wood's lamp).
2.1 Complaints and Anamnesis
See the "Clinical Presentation" section
2.2 Physical Examination
See the "Clinical Presentation" section
2.3 Laboratory Diagnostics
The laboratory diagnostic method for tinea versicolor is microscopic examination of skin scrapings for fungi (yeasts, molds, dermatophytes), which allows the identification of fungal elements in skin scales obtained from the lesions.
It is recommended to perform a microscopic examination of skin scrapings for fungi (yeasts, molds, dermatophytes) in patients with tinea versicolor to confirm the diagnosis [4–8]
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Skin scales obtained from scraping are treated with a 10–20% potassium hydroxide (KOH) solution. A microscopic examination of the scales treated with the 10–20% potassium hydroxide (KOH) solution is then performed with a 20-minute exposure time. Diagnostic significance is attributed to the detection of fungal elements (short curved mycelial filaments (hyphae) 2 to 4 µm in diameter and large round and oval double-contoured spores in clusters resembling bunches of grapes).
It is recommended to determine antibodies of classes M and G (IgM, IgG) to human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) in the blood of patients with tinea versicolor characterized by atypical manifestations or a combination with other skin diseases [9–13].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Tinea versicolor is classified as an HIV-associated disease. Atypical manifestations of tinea versicolor may be a sign of HIV infection.
It is recommended to determine antibodies of classes M and G (IgM, IgG) to human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in the blood of patients with tinea versicolor characterized by atypical manifestations or a combination with other skin diseases [9–13].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Tinea versicolor is classified as an HIV-associated disease. Atypical manifestations of tinea versicolor may be a sign of HIV infection.
2.4 Instrumental Diagnostics
The instrumental diagnostic method for tinea versicolor is luminescence diagnostics (examination under a Wood's lamp), based on the ability of the fungus M. furfur to emit a characteristic yellow or golden-brown fluorescence under ultraviolet irradiation.
It is recommended to perform luminescence diagnostics (examination under a Wood's lamp) in patients with tinea versicolor to confirm the diagnosis [6, 10, 14, 15].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: The diagnosis is established based on the results showing characteristic yellow or golden-brown fluorescence. Fluorescence under Wood's lamp rays is observed in cases where the etiological agent is M. furfur (about 1/3 of patients).
2.5 Other Procedures
It is recommended to perform an iodine test in patients with tinea versicolor to confirm the diagnosis [10, 16].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: When the areas are smeared with 5% iodine tincture, the tinea versicolor spots stain more intensely due to the impregnation of the branny scales with iodine.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Patients with tinea versicolor are prescribed topical antifungal drugs for local application. Their use should be considered preferable in cases of limited skin lesions. In case of scalp involvement, ketoconazole shampoo is convenient to use. In widespread skin lesions or ineffectiveness of topical therapy, systemic therapy with systemic antifungal drugs may be prescribed [2, 10]. A mandatory condition for prescribing systemic therapy is the detection of the pathogen upon microscopic examination. If there is no response to treatment, the systemic antifungal drug is substituted.
3.1 Conservative Treatment
Topical antifungal drugs are recommended for patients with tinea versicolor [2, 10, 17]:
ketoconazole 2% cream for external use once daily until clinical resolution [17–21].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: The usual duration of treatment with ketoconazole cream for pityriasis versicolor is 2-3 weeks. There are no age restrictions for the use of ketoconazole cream.
or ketoconazole 2% shampoo once daily for 3 days, applied to affected skin areas and left for 5 minutes, then rinsed off with water [22, 23].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: The use of shampoo is convenient in cases of scalp involvement. Treatment with ketoconazole shampoo for tinea versicolor may last for 5 days. Ketoconazole shampoo is contraindicated in children under 12 years of age.
or clotrimazole 1% cream for external use, 1% solution for local application applied 2-3 times daily to pre-cleaned (using neutral pH soap) and dry affected skin areas and gently rubbed in [17, 23–26].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: Treatment of tinea versicolor with clotrimazole solution is carried out for at least 1-3 weeks. There are no age restrictions for the use of clotrimazole cream and solution.
or miconazole 2% cream for external use applied to affected areas, with light rubbing, 2 times a day [27–29].
GGR ALEL 2Grade of Recommendation A (Level of Evidence – 2)
Comments: Treatment is carried out until symptoms disappear and for the next few days to prevent relapses (usually 2-6 weeks in total). There are no age restrictions for prescribing miconazole cream.
or naftifine 1% cream for external use, 1% solution for external use [23, 30–32]
For adult patients: Recommendation Grade B (Level of Evidence – 2)
For children: Recommendation Grade C (Level of Evidence – 5)
Comments: The duration of therapy for dermatomycoses with naftifine cream and solution is 2–4 weeks (up to 8 weeks if necessary). In children, naftifine cream and solution should be used with caution.
or terbinafine 1% cream for external use is applied 1–2 times a day to the affected skin; 1% spray for external use is sprayed 2 times a day onto the affected skin areas in an amount sufficient to thoroughly moisten them, and is also applied to adjacent areas of intact skin [10, 32–36].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: The duration of therapy with terbinafine cream is on average 2 weeks, and with terbinafine solution, 1 week. Use in children is possible according to the dosing regimen. A contraindication for prescribing terbinafine cream is age under 12 years. A contraindication for prescribing terbinafine spray is age under 18 years.or
#oxiconazole 1% cream for external use is applied in a thin layer to the affected areas 2 times a day [37].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: The duration of the course of treatment with oxiconazole cream for pityriasis versicolor is 2 weeks. A contraindication for prescribing oxiconazole cream is age under 8 years.
or sertaconazole 2% cream for external use should be applied to the affected skin areas 2 times a day, capturing approximately 1 cm of the surface of healthy skin [38–40]
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: As a rule, the symptoms of the disease disappear within 2–4 weeks, but the recommended duration of treatment is 4 weeks. There are no data on the use of sertaconazole cream in children.
Recommended topical antifungals for patients with pityriasis versicolor involving the scalp for external therapy:
ketoconazole 2% shampoo once a day for 3 days, applied to the affected areas of the scalp and left for 5 minutes, then rinsed off with water [10, 40].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Treatment with ketoconazole shampoo for pityriasis versicolor may last for 5 days. Ketoconazole shampoo is contraindicated in children under 12 years of age.
Recommended systemic antifungals for patients with pityriasis versicolor presenting with widespread rashes, as well as in cases of ineffectiveness of topical therapy for localized lesions or frequent recurrences [2, 10]:
itraconazole 200 mg orally once daily every day for 1 week [32, 41, 43, 40–42 ].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: If isolated rashes persist after a 2-week break, a repeated course of treatment should be carried out at the same dose. A contraindication for prescribing itraconazole is age under 3 years.
or #itraconazole 100 mg orally once daily after meals for 14 days [43]
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: After 2 weeks of treatment with #itraconazole at a dose of 100 mg per day, cure was noted in 66.7% of patients with pityriasis versicolor [44]. A contraindication for prescribing itraconazole is age under 3 years.
or ketoconazole [17, 23, 32, 45–47].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: According to the instructions for use of the medicinal product for medical use – for adult patients and children with a body weight of more than 30 kg – 200 mg orally once daily every day for 2–5 weeks36. A contraindication for prescribing ketoconazole in tablet form is age under 3 years.
or fluconazole** for adults and children 300 mg orally once a week for 2–3 weeks or 150 mg once a week orally for 4 weeks [6, 47–52].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comments: A contraindication for prescribing fluconazole** is age under 3 years.
3.2 Surgical Treatment
Not applicable.
3.3 Other Treatment
Dietary therapy is not used.
Pain management is not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable.
5. Prevention and Dispensary Observation
Recommended for patients with pityriasis versicolor who are prone to recurrences of the disease, for the purpose of recurrence prevention:
#itraconazole 400 mg once a month for 6 months (A contraindication for prescribing itraconazole is age under 3 years.) [53].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: Restoration of normal skin appearance, despite successful treatment, may take several months, especially in the presence of hypo- (hyper-) pigmented areas. An important criterion for cure is a negative result of microscopic examination.
6. Organization of Medical Care
Primary specialized health care for patients with pityriasis versicolor is provided on an outpatient basis by a dermatologist.
There are no indications for hospitalization in a medical organization.
7. Additional Information
Exposure to sunlight should be avoided, as this may impair color contrast due to the fact that the affected skin will not be able to tan. Subsequently, the affected skin resumes normal pigment production.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1. | Microscopic examination of skin scrapings for fungi (yeasts, molds, dermatophytes) was performed | Yes/no |
2. | Luminescent diagnostics (examination under a Wood's lamp) was performed | Yes/no |
3. | Therapy with topical or systemic antifungals was administered | Yes/no |
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Appendix A1. Working Group Composition
Kubanov Aleksey Alekseevich – Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, President of the Russian Society of Dermatovenereologists and Cosmetologists.
Eremina Maria Gennadievna – Candidate of Medical Sciences, Associate Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.
Morrison Anna Vitalievna – Candidate of Medical Sciences, Associate Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.
Sidorenko Olga Anatolievna – Doctor of Medical Sciences, Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.
Stepanova Olga Viktorovna – Dermatovenereologist, Member of the Russian Society of Dermatovenereologists and Cosmetologists.
Tlish Marina Mossovna – Doctor of Medical Sciences, Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.
Chikin Vadim Viktorovich – Doctor of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.
Conflict of interest: the authors declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Medical specialists: dermatovenereologists.
Residents and trainees of continuing professional education programs in the specified specialty.
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
These clinical guidelines were developed taking into account the following regulatory legal documents:
Procedure for the provision of medical care in the profile «dermatovenereology», approved by Order of the Ministry of Health of the Russian Federation No. 924n dated November 15, 2012.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Restoration of normal skin appearance, despite successful treatment, may take several months, especially in the presence of hypo- (hyper-) pigmented areas.
Family members should also be examined and treated if they are diagnosed with the disease.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Special assessment scales, indices, and questionnaires specifically for pityriasis versicolor are not used in the examination of patients.