History

Fact Explanation
Abnormal depigmented macules involving skin regions. Pityriasis versicolor is a common superficial fungal infection caused by commensal yeasts of genus Malassezia. Overgrowth of these yeasts is responsible for clinical lesions. Carboxylic acids released by the organisms through oxidation of unsaturated fatty acids of skin surface competitively inhibit tyrosinase, the enzyme of pigment production in melanocyte. It results Hypopigmented macules. But, sometimes an enlargement of melanosomes made by melanocytes resulting hyperpigmented macules is induced by the organism. [1],[4],[5]
Fine scaly lesions. Pityriasis versicolor is a superficial fungal infection localized to the stratum corneum. It is a dead cell layer which produces fine scales of keratin. [1],[2],[5]
Mild itching Sometimes patients experience mild itching, usually when the person's body temperature is elevated just before starting sweating by exercise or warm environment .Once sweating begins the itching subsides. [1]
Common in young adults Pityriasis versicolor is caused by lipophillic organisms. Sebaceous glands are more active during puberty. High lipid content of sebum provides a good media on skin surface to causative organisms. [2],[5]
Living in a hot climate. This is an uncommon disorder in temperate zones and seen even more frequently in topical climates. People who live or work in hot humid climate experience increased sweating. The pathogenic growth of causative organisms of Pityriasis versicolor is encouraged by sebum rich environment on skin surface. [1], [3],[5]
Immunosuppression Their may be a positive history of immunosuppression as this is a relatively common disorder among patients with AIDS, Cushings syndrome, longterm use of corticosteroids and in patients with immune deficiency disorders. It is accepted now that CMI is the main mechanism of defense against fungal infections, but that certain types of antibody response are protective. Therefore suppressed immunity leads to pathogenic growth of causative organisms. [2]
Malnutrition Their may be a history of malnutrition, as it weakens the defense system against infections resulting inadequate immunity against fungal infections. Therefore They are more prone to pathogenic growth of yeasts of genus Malassezia. [2]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 254-256.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th ed. Arnold publishers. 2003, 37-38.
  3. GRAHAM-BROWN, Robin and BURNS, Tony. Lecture notes: Dermatology. 10th Ed. Willy-Blackwell. 2011,38-39.
  4. BUXTON, Paul K. and MORRIS-JONES, Rachael. ABC of Dermatology. 5th Ed. Willy-Blackwell. 2009,118-119.
  5. SANTANA, Juliano Oliveira. DE AZEVEDO, Fernanda Luiza Andrade and FILHO,Pedro Costa Campos. Pityriasis versicolor: clinical-epidemiological characterization of patients in the urban area of Buerarema-BA, Brazil. Anais Brasileiros de Dermatologia-Official publication of Brazilian Society of Dermatology. 2013 Mar-Apr; 88(2): 216–221. [Viewed on 26/03/2014]. doi: 10.1590/S0365-05962013000200005

Examination

Fact Explanation
Numerous, well demarcated macules with fine scales. Initially appear as oval-to-round macules, as they grow, coalesce forming irregular shapes.Pityriasis versicolor is a superficial fungal infection localized to stratum corneum. It produces fine scales of keratin with minimal scraping. [1],[2],[3],[4]
Predominantly involve upper trunk. Scattered over the upper trunk involving chest, back, neck and under the upper arms. This area of the body has number of sebaceous glands which provides good medium to pathogenic growth of lipophillic causative organisms. But the lesions can occur anywhere of the body. [1], [3],[4],[5]
Hyperhidrosis. Hyperhidrosis is a medical condition in which a person sweats excessively and unpredictably. Local hyperhidrosis is common among young adults. Pityriasis versicolor is comparatively common among people with hyperhidrosis due to sebum rich skin surface. Therefore excessive sweating of the palms, soles and and axillae may be a noticed during examination. [1],[2],[5]
Features of Cushings syndrome. Pityriasis Versicolor is relatively common among patients with suppressed immunity due to longterm steroid treatment or Cushings syndrome. Signs of Cushings syndrome such as moon face, plethora, 'buffalo hump', purple striae, thin skin, proximal myopathy, hypertension may be noticed during examination. [6]
Feautures of malnutrition. Malnutrition weakens immunity. Signs of macro and micro nutrient deficiencies such as dry eyes, pale conjunctiva, Bitot's spots, Angular stomatitis, cheilitis, glossitis, spongy bleeding gums,enamel mottling, brittle hair,dry eyes,poor wound healing may also be noticed during examinations. [6]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 173-175, 254-256.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17thEd. Arnold publishers. 2003, 37-38.
  3. GRAHAM-BROWN, Robin and BURNS, Tony. Lecture notes: Dermatology. 10th Ed. Willy-Blackwell. 2011,38-39.
  4. BUXTON, Paul K. and MORRIS-JONES, Rachael. ABC of Dermatology. 5th Ed. Willy-Blackwell. 2009,118-119.
  5. SANTANA, Juliano Oliveira. DE AZEVEDO, Fernanda Luiza Andrade and FILHO,Pedro Costa Campos. Pityriasis versicolor: clinical-epidemiological characterization of patients in the urban area of Buerarema-BA, Brazil. Anais Brasileiros de Dermatologia-Official publication of Brazilian Society of Dermatology. 2013 Mar-Apr; 88(2): 216–221. [Viewed on 26/03/2014]. doi: 10.1590/S0365-05962013000200005
  6. KUMAR, Parveen and CLARK, Micheal. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012, 200-213, 957-958.

Differential Diagnoses

Fact Explanation
Erythrasma Commonly present with macular, wrinkled, slightly scaly, pink, brown or macerated white areas most often found in the armpits or groins, or between toes. [1]
Pityriasis alba Present as poorly marginated, light patches on pigmented skin. Often affects the cheeks. [1]
Pityriasis rosea Most patients develop one plaque before the others. It is larger (2-5cm) than other lesions, and is rounder, redder and more scaly. After few days many smaller plaques appear, mainly on the trunk. Most of the patients complain of itching. [1],[3]
Guttate psoriasis Characterized by numerous small drop shaped papules come up suddenly on trunk and soon become scaly. The lesions are mildly itching. There is a preceding history of streptococcal tonsillitis. [1],[3]
Seborrhoeic eczema Eczematous disorder. Mainly affects hairy areas, on flexures and on central part of trunk. Shows characteristic greasy yellowish scales. [1],[2],[3]
Tinea corporis The typical appearance is round or annular, red, scaly, well marginated lesion. The lesions expand slowly and healing in the center leaves a typical ring like pattern. [1],[2]
Leprosy The first peripheral sign is hypo pigmented plaque with accompanying sensory loss over the lesion. The range of clinical manifestations and complications depend upon the immune response of the patient. [1],[3]
Vitiligo The border is clearly defined, scaling is absent, lesions are larger, the limbs and face are often affected and depigmentation is more complete. Commonly associated with other autoimmune disorders. [1],[3]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 54-70, 71-72, 97-99, 207-208, 221, 230-234, 249-250, 254-256.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17thEd. Arnold publishers. 2003, 37-38, 39-40, 114-117.
  3. KUMAR, Parveen and CLARK, Micheal. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 130-132, 2012, 1200, 1203-1207, 1211, 1229-1230.

Investigations - for Diagnosis

Fact Explanation
Wood's lamp examination Woods lamp examination allows for close dermatological examination of the skin. The long wave ultra violet light demonstrates a coppery orange fluorescence in Pityriasis versicolor. [1],[2]
Light microscopic examination. The skin scrapings prepared with potassium hydroxide to be observed by light microscope. The short branched hyphae and spores show a characteristic " spaghetti and meat balls" appearance. [1],[2],[3]
Culture Culture is not helpful because the organism does not grow on Sabouraud's medium. Special media is required. However as diagnosis can be confirmed by microscopic appearance cultures are rarely performed. [1]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 254-256.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17thEd. Arnold publishers. 2003, 37-38.
  3. GRAHAM-BROWN, Robin and BURNS, Tony. Lecture notes: Dermatology. 10th Ed. Willy-Blackwell. 2011,38-39.

Management - General Measures

Fact Explanation
Patient education Advise the patient that Pityriasis versicolar is a common benign superficial fungal infection caused by commensal yeasts. Overgrowth of these yeasts is responsible for clinical lesions. It does not cause a permanent scar, but it will take some time to regain color of depigmented areas. Emphasize that this can be treated successfully, but recurrence is common. [1], [2]
Advise about hygiene. Advise the importance of daily bathing, washing clothes regularly and wearing clean dry clothes to prevent recurrence. [1],[2]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 254-256.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17thEd. Arnold publishers. 2003, 37-38.

Management - Specific Treatments

Fact Explanation
Topical anti fungal of the imidazole group Topical imidazole creams (Eg. Miconozole, Clotrimazole, Econozole) to be applied once daily for 2-4 weeks. The azoles interfere with fungal oxidative enzymes to cause lethal accumulation of hydrogen peroxide. They also reduce formation of ergosterol an important constituent of fungal cell wall which thus becomes permeable to intracellular constituents. [1],[2],[3],[4]
Ketoconozole shampoo It is easy to use, and as equally effective as Imidazole cream. [1], [2]
2.5% Selenium sulphide mixture in a detergent base This should be applied over lesions after an evening bath, allow to dry and wash off the next morning. Three applications at weekly intervals are adequate. This is equally effective as imidazole but more irritant. [1]
Selenium sulphide lotion Apply for 10 min and rinse off, use daily for 1 week. [1]
Systemic antifungals For widespread Pityriasis versicolor infections; oral Traconazole, Fluconazole or Ketoconazole may be curative. But interactions with other drugs Should be considered as they inhibit the hepatic cytochrome P450 enzymes. [1], [3],[4]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 254-256.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17thEd. Arnold publishers. 2003, 37-38.
  3. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. McGraw Hill companies. 2012, 853-855.
  4. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 265-267.