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A 21-year-old man comes to the office due to a rash.  The rash began several months ago and became more noticeable over the summer.  The patient works as a lifeguard at a hotel swimming pool and has had "5 or 6" sexual partners in the last year.  Vital signs are normal.  Examination shows scattered macules across the shoulders, chest, and upper back, as shown in the exhibit.  After diagnostic confirmation, which of the following is the most appropriate treatment for this patient's skin condition?

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Explanation:

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Tinea versicolor (pityriasis versicolor)

Pathogenesis

  • Malassezia globosa skin flora grows in exposure to hot & humid weather

Clinical features

  • Hypopigmented, hyperpigmented, or mildly erythematous lesions (face in children, trunk & upper extremities in adolescents & adults)
  • ± Fine scale
  • ± Pruritus

Diagnosis

  • KOH preparation shows hyphae & yeast cells in a "spaghetti & meatballs" pattern

Treatment

  • Topical ketoconazole, terbinafine, or selenium sulfide

KOH = potassium hydroxide.

This patient has a chronic macular rash that is consistent with tinea versicolor (TV).  TV (also called pityriasis versicolor) is a superficial fungal skin infection caused by Malassezia species (eg, M globosa, M furfur—nondermatophytic, lipid-dependent yeasts).  It is characterized by hyperpigmented, hypopigmented, or salmon-colored macules that are sometimes covered by fine scales, most commonly on the upper trunk and the extremities.  TV is often worse during the warm summer months and can become more apparent after tanning of the surrounding skin.

The diagnosis of TV can be confirmed with potassium hydroxide (KOH) preparation of skin scrapings showing large, blunt hyphae and thick-walled budding yeast ("spaghetti and meatballs" appearance).  Topical treatment with selenium sulfide or ketoconazole is recommended, but the pigmentation changes can take months to resolve following treatment.

(Choice A)  Topical corticosteroids are used for a variety of skin disorders (eg, psoriasis, vitiligo) but can promote growth of Malassezia fungi and worsen TV.

(Choice B)  Penicillin G is used for treatment of secondary syphilis, which can present with a macular rash but is typically generalized, affecting the entire body, including the palms and soles.

(Choice C)  Avoiding sun exposure may make TV less noticeable but would not lead to resolution of the infection.

(Choice D)  Oral antihistamines are used for urticaria, which presents acutely (minutes to hours) as well-circumscribed, erythematous plaques with intense pruritus and associated edema (ie, wheals).  The lesions typically resolve within 24 hours.

Educational objective:
Tinea versicolor is a superficial fungal skin infection characterized by hyperpigmented, hypopigmented, or salmon-colored macules on the upper trunk and the extremities.  It is often worse during the summer months.  The diagnosis can be confirmed with potassium hydroxide preparation of skin scrapings.  Treatment includes topical selenium sulfide or ketoconazole.