Round scaly patches on the chest
Background
This 25-year-old man has got round, brown, scaly patches over his chest. It has been diagnosed as a fungal infection but has not responded to oral terbinafine for two weeks.
What is this condition?
The superficial brown scaly patches are highly suggestive of a yeast infection called pityriasis versicolor — it is due to a yeast called Malassezia and not a dermatophyte fungus.
How can the diagnosis be confirmed?
The best way to confirm the diagnosis is by taking skin scrapings. The yeast pseudohyphae and spores are said to resemble spaghetti and meatballs when looked at using a potassium hydroxide wet preparation on microscopy.
How should it be treated?
Unfortunately, it does not respond to oral terbinafine, which is highly active against dermatophyte fungi but not the causative yeast. It can be treated by using topical azole shampoos or creams, or a short course of oral itraconazole.
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Comments
15 September 26
Mukhtar Ali
Kudos for clear explanation of treatment options
30 August 26
Georgeta
Pytiriasis versicolor
Topical azoles, terbinafină 1%cream
Oral itraconazole
30 August 26
Dr.Syed Waqar Haider
Selenium sulphide shamoo can be tha altrrnative modaloty of treatment
27 August 26
Minhaj
Thank you for enlightening us on the Mx of a common condition and the potential pitfalls in its management.
27 August 26
Mebratu
Excellent case! Pityriasis (tinea) versicolor is a great example for distinguishing a superficial fungal infection from other skin conditions with similar pigmentary changes. Having a clear understanding of the clinical features and appropriate diagnostic tests, such as the KOH examination, is essential for making the correct diagnosis and avoiding unnecessary treatment.
27 August 26
Elham Mutahar
Thank you for this informative information. Pityriasis versicolor also responded to fluconazole cap.
27 August 26
Maiada
Thanks for this great case
26 August 26
Ben
I agree KOH may show pityriasis versicolor. But if it shows fungi it may be resitent
26 August 26
Hajar
Pityriasis rotunda
26 August 26
Peter
I always think of Terbinafine to be akin to narrow spectrum bacteriocidal antibiotics, such as flucloxacillin. Oral Azoles are more akin to bacteriostatic broad spectrum antibiotics such as tetracycline. Both will have activity against Dermatophytes, with Terbinafine being more effective. Whereas Terbinafine is ineffective against yeasts. You will not get cosmetic clearance of Pityriasis Versicolor using oral Azoles alone. The epidermal layer of the skin will need to be disrupted by physical methods such as scrubbing to clear the pigmentation. This is why I prefer topical treatments. In the past Selenium sulphide shampoo (no longer available)diluted to 50% and left on nightly for a few hours then scrubbed off in the morning worked within 2 to 3 weeks.
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