Tinea Versicolor: Everything You Need to Know

Tinea versicolor, also known as pityriasis versicolor, is a fungal infection of the skin caused by yeast of the Malassezia family. While Malassezia normally resides on the skin, causing no harm, it can overgrow and establish an infection.

Tinea versicolor is so named because it causes superficial white, tan, or pink patches on the skin that can darken and change when the body is overheated. The yeast infection, along with the skin discoloration, will usually resolve with the use of topical antifungal drugs. Harder-to-treat cases may require oral antifungals.

This article looks at the cause and symptoms of tinea versicolor, including how the infection is diagnosed and treated. It also explains how to prevent tinea versicolor and when it is time to see a healthcare provider.

What Causes Tinea Versicolor?

Tinea versicolor is a common skin infection affecting 1% of the general population and up to 40% of people who live in tropical climates. The majority of cases involve the fungal species Malassezia globosa, while a small proportion is attributed to Malassezia furfur, Malassezia sympodialis, and other minor species.

Under normal circumstances, Malassezia is well controlled by the immune system and lives in balance with other yeast and bacteria on the skin (referred to as the cutaneous flora). However, when the balance is disrupted, Malassezia can overgrow and cause an outbreak of superficial skin lesions.

Because Malassezia feeds on fats found in skin oils (called sebum), outbreaks tend to occur where there is a high density of sebum-producing sebaceous glands (such as on the face, scalp, and upper body).

Risk factors for tinea versicolor include:

• Being immunocompromised (having a weakened immune system, such as people with untreated human immunodeficiency virus (HIV), organ transplant recipients, or those undergoing chemotherapy)
• Taking broad-spectrum antibiotics that can wipe out bacteria on the skin and trigger an imbalance of the cutaneous flora
• Sweating excessively, such as during sports, which increases sebum production
• Living in hot, humid climates that promote sweating
• Using oils or cosmetics that can clog skin pores and allow sebum to pool

Genetics are thought to play a part as tinea versicolor tends to run in families. Several genetic mutations associated with tinea versicolor have already been identified.

What Are the Symptoms of Tinea Versicolor?

Tinea versicolor is painless and often involves no other symptoms than the characteristic discolored lesions.

Some cases of tinea versicolor cause hypopigmentation (lightening of the skin) while others cause hyperpigmentation (darkening of the skin). A person's skin tone is also a factor, as a lesion may appear lighter on dark skin and darker on light skin.

When a body is overheated or exposed to the sun, the lesions can appear to change color, mainly because overheated and sun-exposed skin can darken, but the fungal patches do not.

Common symptoms of tinea versicolor include:

• Small circular skin patches that grow and gradually merge into larger, irregularly shaped patches
• Patches that appear white, yellowish, tannish, or pink, mainly on the neck, upper back, chest, and shoulders of adults and on the face and neck of children
• Skin dryness or scaling
• Mild itching, mainly when the skin is overheated

Though tinea versicolor is generally harmless, it can be difficult to treat and cause emotional distress or self-consciousness if an outbreak is severe or recurs frequently.

Similar Conditions

Some other conditions have similar symptoms to tinea versicolor. To ensure the correct diagnosis and treatment, medical examination and testing may be needed.

Examples include:

• Tinea corporis: A type of ringworm caused by one of over 40 fungal species
• Pityriasis alba: A non-fungal skin condition of unknown origin that causes white patches
• Vitiligo: An autoimmune skin condition that causes the progressive loss of skin pigmentation
• Nummular eczema: An immune-mediated skin condition that causes sharply defined, coin-shaped lesions that are pink, reddish, or brown
• Guttate psoriasis: A form of the autoimmune disease psoriasis that causes tear-shaped, pink bumps on the torso, arms, and legs

How Is Tinea Versicolor Diagnosed?

Tinea versicolor is diagnosed in the same way as other fungal skin infections: with a physical exam, microscopic evaluation, and the exclusion of all other causes, known as differential diagnosis. The tests are best conducted by a skin specialist known as a dermatologist.

The three tools central to the diagnosis are:

• KOH prep test: This is a test in which a scraping of skin is exposed to potassium hydroxide (KOH). KOH dissolves the tissues, only leaving the fungus behind. Under the microscope, Malassezia has characteristic buds and stalks often described as a "spaghetti-and-meatballs" formation.
• Wood's lamp: This is a noninvasive test in which the skin lesions are exposed to a black light. If Malassezia is involved, the patches will turn a fluorescent yellowish-orange under the light. Other bacterial and fungal infections turn a different color.
• Fungal skin culture: If there is any doubt about the cause (or the infection frequently recurs or is resistant to treatment), a scraping of skin can be sent to the lab to grow the fungal spores. The sample can then be submitted for visual and genetic tests to confirm the diagnosis.

If Malassezia is not found, other tests will be ordered to narrow the possible causes.

Can You Treat Tinea Versicolor At Home?

Malassezia is a hardy fungus that tends to persist once an infection has been established. Tinea versicolor may improve in cooler or drier weather but usually does not go away on its own.

Mild Malassezia infections can often be treated at home. Many of the same over-the-counter (OTC) antifungal drugs used to treat ringworm or athlete's foot also work for tinea versicolor.

OTC antifungal options include:

• Lamisil (1% terbinafine) cream
• Lotrimin AF (1% clotrimazole) cream
• Lotrimin Ultra (1% butenafine) cream
• Nizoral (1% ketoconazole) shampoo
• Tinactin (1% tolnaftate) cream

The effectiveness of these medications can vary. Of the OTC options, 1% terbinafine is arguably the most widely studied and offers cure rates of up to 70% in people with mild Malassezia infection.

To prevent the worsening of skin discoloration, avoid excess sun exposure and wear a high-SPF sunscreen until the infection is fully healed.

If there is skin dryness, scaling, or itching, apply a light emollient moisturizer after bathing or showering. Itching can also be reduced if you avoid overheating the body.

How Is Tinea Versicolor Treated With Prescriptions?

If OTC remedies fail to provide relief, you may need to seek treatment from a dermatologist. Topical antifungal drugs remain the mainstay of treatment, albeit at concentrations higher than what is used in OTC options.

Prescription topical antifungal options include:

• Nizoral (2% ketoconazole) cream, gel, or shampoo
• Penlac (0.77% ciclopirox) cream, gel, or shampoo
• Selsun (2.5% selenium sulfide) lotion or shampoo

Oral antifungals are reserved for people with severe disease (often due to a weakened immune system), frequent recurrences, or infections that fail to improve with topical treatment.

While oral antifungals are faster and more effective in clearing an infection, they can cause significant and potentially severe side effects, including fatigue, irregular heartbeat, nausea, vomiting, trouble breathing, and seizures.

Prescription oral antifungal options include:

• Diflucan (fluconazole) tablets or oral solution
• Sporanox (itraconazole) tablets, capsules, or oral solution

For people with severely compromised immune systems, antifungal treatment may need to be repeated or continued at a low dose to prevent recurrence.

How Long Does It Take Your Skin to Return to Normal?

Topical antifungals like 1% terbinafine, used once or twice daily, can usually clear a Malassezia infection within two to three weeks (although some cases may take up to eight weeks). Oral antifungals like Sporanox can usually clear an infection within 10 days with a once-daily dose.

Even after successful treatment, the uneven skin discoloration can persist for weeks and even months. While your skin tone should eventually begin to normalize, you should continue to use sunscreen with a high sun protection factor (SPF) until it does.

In hot, humid climates, tinea versicolor can often recur during the summer months. If you are prone to recurrence, ask your healthcare provider if taking a once- or twice-monthly preventive dose of Sporanox can help.

How Can You Prevent Tinea Versicolor?

Tinea versicolor can't always be prevented, the following 10 measures may help if the condition is triggered by hot temperatures:

• Avoid excessive heat exposure, staying indoors when the sun is at its hottest.
• Wear light, airy clothing while outdoors.
  
• If you are an athlete, wear moisture-wicking clothes that promote sweat evaporation and keep the body cool.
• Keep well hydrated while outdoors or exercising.
• If you get very sweaty, take a cool shower as soon as possible and dry the skin thoroughly.
• Use a fan or air-conditioner at night to avoid sweating.
• Avoid skin care products that are oily, thick, or greasy.
• If you get tinea versicolor on the face, avoid heavy foundation makeup and use a light powder instead.
• Ask your pharmacist about OTC antifungal powders you apply to the body if you plan to be outdoors in the heat.
• Always wear sunscreen.

When to Contact a Healthcare Provider

Many cases of tinea versicolor can be effectively treated at home, but there are times when it is in your best interest to seek medical treatment.

You should contact your healthcare provider or see a dermatologist if:

• Your condition does not improve after four weeks of OTC topical treatment.
• Your condition worsens despite OTC or prescription antifungal treatment.
• Your condition develops rapidly, severely, or involves large areas of skin.
• You experience seasonal recurrence or recurrence after successful treatment.
• You develop tinea versicolor on the face and want to get rid of it fast.
• You are immunocompromised and have tinea versicolor.
• You are not sure whether you have a fungal skin condition.

Summary

Tinea versicolor is a harmless, painless, but potentially disruptive skin condition caused by a type of fungus called Malassezia. It commonly affects people who are immunocompromised, are taking antibiotics, or live in hot, humid climates.

Symptoms include dry, circular patches of skin that meld into larger areas of discoloration. The patches mainly develop where there are lots of sweat glands. Tinea versicolor can usually be diagnosed with a physical exam, KOH prep test, and a Wood's lamp.

The mainstay of treatment is topical antifungals and occasionally oral antifungals. Recurrent cases may benefit from preventive doses of antifungal medications or by avoiding overheating the body in hot, humid temperatures.