Diagnosis and Management of Tinea Versicolor in India

Tinea versicolor (Pityrosporum folliculitis) is the most common superficial fungal infection in India, affecting up to 30% of the population. Accurate diagnosis and tailored therapy are essential to avoid chronic relapses, cosmetic disfigurement, and unnecessary drug exposure.

1. Clinical Presentation

• Hypo‑ or hyperpigmented macules and patches on trunk, upper arms, neck.
• Fine scaling; lesions may be more pronounced in winter or after hot showers.
• No pruritus in most cases; mild itching may occur if secondary bacterial infection is present.

2. Diagnostic Work‑up in India

A. Direct Microscopy (KOH Preparation)

• Collect scale from lesion edge using sterile curette.
• Place sample on slide, add 10–20% potassium hydroxide, cover with coverslip.
• Examine under 10× or 40× objective; look for spaghetti‑and‑meatball appearance of Malassezia spp.
• Result available within 15–20 minutes; high sensitivity in active lesions.

B. Fungal Culture (Sabouraud Dextrose Agar with Cycloheximide)

• Culture material: skin scrapings, scales, or swabs from lesion margins.
• In India, most tertiary care labs (e.g., AIIMS, PGIMER) and private diagnostics (SRL Diagnostics, Thyrocare) provide Sabouraud media.
• Incubate at 28–30 °C for up to 4 weeks; colonies appear as yellowish‑brown, cottony, with a distinctive “spaghetti” hyphal pattern.
• Identifies species (M. furfur, M. globosa) and informs antifungal susceptibility if needed.

C. Wood’s Lamp Examination (Optional)

• Some lesions fluoresce yellow‑green under Wood’s lamp due to porphyrin production.
• Useful in resource‑limited settings but not definitive; false negatives common.

3. Treatment Options in India

Treatment choice depends on disease extent, patient age, comorbidities, and drug availability. The following outlines topical versus systemic therapy with typical Indian medications.

A. Topical Antifungals

• Ketoconazole 2% Cream (e.g., Nizoral®)
  • Apply once daily to affected areas for 4–6 weeks.
• Clotrimazole 1% Cream (e.g., Clio®)
  • Same dosing; cheaper and widely available in local pharmacies.
• Terbinafine 1% Lotion (e.g., Lamisil®)
  • Apply twice daily for 2–4 weeks; higher efficacy in resistant cases.
• Azelaic Acid 15–20% Gel (e.g., Azext®)
  • Useful in hyperpigmented variants; apply twice daily for 6–8 weeks.
• Prescription‑only preparations (e.g., Ciclopirox 8% Ointment)
  • Considered when other agents fail; monitor for irritation.

B. Systemic Antifungals (for extensive or recalcitrant disease)

• Terbinafine 250 mg PO once daily
  • Treatment duration: 2–4 weeks; monitor liver enzymes if >8 weeks.
• Itraconazole 200 mg PO twice daily (pulse therapy)
  • Take for 3 days per week (e.g., Monday, Wednesday, Friday) over 4–6 weeks.
• Griseofulvin 250–500 mg PO twice daily
  • Alternative in children; less effective against Malassezia but useful when systemic therapy contraindicated.
• Ketoconazole 200 mg PO twice daily
  • Reserved for severe cases; requires liver function monitoring.

C. Adjunctive Measures

• Maintain skin dryness; avoid hot showers and humid environments.
• Use non‑comedogenic moisturizers to reduce irritation from topical agents.
• Educate patients on adherence; relapse rates high if therapy is stopped prematurely.

4. Follow‑Up and Relapse Prevention

• Re‑evaluate in 4–6 weeks with repeat KOH or culture if symptoms persist.
• Offer prophylactic topical therapy (e.g., 1% clotrimazole) for 2–3 months post‑resolution.
• Screen for underlying immunosuppression (e.g., diabetes, HIV) if recurrent lesions occur.

5. Common Pitfalls in Indian Practice

• Over‑use of topical steroids. Many patients self‑medicate with steroid creams, worsening fungal proliferation.
• Inadequate dosing of systemic agents. Some clinicians prescribe low doses of terbinafine, leading to treatment failure.
• Neglecting comorbidities. Diabetes or malnutrition can predispose to severe disease; address concurrently.

6. Summary of Evidence‑Based Recommendations for Indian Clinicians

• Confirm diagnosis with KOH and, when possible, fungal culture.
• Start topical ketoconazole or clotrimazole for <5 cm² lesions; consider systemic terbinafine for >5 cm² or recalcitrant disease.
• Monitor liver function for systemic therapy >4 weeks.
• Provide patient education on skin hygiene and adherence to reduce relapse rates.

• Share