PITYRIASIS

VERSICOLOR
PRESENTER: DR VALENTINA T. DANIEL
10TH JUNE 2023
OUTLINE
•- Introduction
•- Etiology
• epidemiology
•- Risk factors
•- Pathogenesis/pathophysiology
•- Clinical presentation
•- Differential diagnosis
•- Investigations
•- Treatment
INTRODUCTION
• Pityriasis versicolor (PV), also known as tinea versicolor, is a common
chronic, benign, superficial cutaneous fungal infection caused by
Malassezia yeasts, which are part of the many microscopic organisms
that normally live on the skin.
• Infection usually results from change from its lipophilic yeast form to
mycelial form of Malassezia
• It is localized to the stratum corneum and usually characterized by
hypopigmented or hyperpigmented macules and patches on the chest
and the back.
AETIOLOGY

Pityriasis versicolor is caused by dimorphic lipophilic organisms in the genus

Malassezia formerly known as pityrosporum.

Fourteen species are recognized in this classification of Yeast of which

Malassezia globosa , Malassezia sympodialis and Malassezia furfur are
predominant species isolated in P. versicolor.

Most cases of tinea versicolor occur in healthy individuals with no

immunologic deficiencies.
• Nevertheless, several factors predispose some people to develop this
condition.
• These factors include:- genetic predisposition; warm, humid
environments; immunosuppression; malnutrition; application of oily
preparations; corticosteroid usage;
Cushing disease.
• The use of bath oils and skin lubricants may increase the risk of
developing tinea versicolor
Epidemiology
• Pityriasis versicolor has a worldwide distribution, but it is more
common in tropical countries, with prevalence ranging from 2.3% in
the Philippines to 16.3% to 17.8% in Malawi.
• There were 2.9 million visits to family doctors per year for pityriasis
versicolor in a US national survey, which accounted for around 29% of
all dermatomycoses seen at dermatology clinics.
• Pityriasis versicolor affects mainly adolescents and young adults aged
10 to 30 years, but may occur in individuals of all ages, including
infants and the elderly.
PATHOGENESIS
• Malassezia furfur is a fungus that can exist as both a yeast and as a
mold (a dimorphic fungus).
• It is normally a harmless component of normal skin flora but in some
people causes tinea versicolor.
• Most affected people are healthy.
• Factors that may predispose to tinea versicolor include heat and
humidity and immunosuppression due to corticosteroids, pregnancy,
undernutrition, diabetes, or other disorders.
• Hypopigmentation in tinea versicolor is due to the inhibition of
tyrosinase caused by M. furfur production of azelaic acid.
pathogenesis
Malassezia metabolizes various fatty acids like arachidonic acids acid via lipase
to release azelaic acid
Azelaic acid inhibits tyrosinase in the production of melanin resulting in
persistent hypopigmentation of affected skin for months or sometimes years.
Specific compounds synthesized by Malassezia are called pityriacitrins that
absorbs UV light and causes hyperpigmentation.
Other metabolites include:
a) Malassezin : Induces apoptosis of melanocytes.
b) Pityrialactone : an indole alkaloid that flourescences under 300nm UV
light
c) Pityriarubin : inhibits 5-lipoxygenase enzymes
CLINICAL PRESENTATION
Patients with pityriasis versicolor present with multiple, well-demarcated,
oval, finely scaling patches or plaques.
Skin lesions may be hypopigmented, hyperpigmented, or erythematous and
occasionally become confluent and widespread.
The fine scales may not be readily apparent on the lesions, but it is easily
provoked when the affected skin is stretched or scraped.
The distribution of affected skin reflects the lipophilic nature of the fungus
since the seborrheic areas (trunk, neck, and/or arms) are predominantly
involved. The face also may be affected, particularly in children. Pityriasis
versicolor skin lesions are usually asymptomatic or slightly pruritic. However,
severe pruritus can be present in very warm and humid conditions.
FORM 1: Most Common Form
- Patient with pityriasis versicolor present with a rash consisting of well
demarcated, finely scaling hypopigmented (less commonly hyperpigmented or
erythematous) macules mainly starts around perifollicular region.
- Scale is fine and powdery
- commonest site of lesions are on oily regions which are also very sweaty
like upper trunk often spreading to the neck and upper arms.
- Scratch sign: Lesion surmounted by branny scales which can be accentuated by
scratching lesion gently with the help of glass slides. This sign is also known as
‘coup d’ongle sign’ or ‘Besnier’s sign’ or ‘Stroke of the nail sign’
• Itching is minimal but mild pruritus may be present
• FORM 2 : Inverse Form
•- Distributed typically in flexural region
•- More commonly seen in immunocompromised
• FORM 3 : Folliculitis form
•- Perifollicular erythematous papule or pustule
• FORM 4 : Multiple , Firm , Red-Brown inflammatory papules
•- May or may not demonstrate scales
•- Usually found on torso and usually asymptomatic
Differential diagnoses
• HYPOPIGMENTED LESIONS HYPERPIGMENTED LESIONS
•- Vitiligo • Nummular Eczema
•- Pityriasis alba • Confluent and Reticulate
•- Leprosy papillomatosis
• HYPERPIGMENTED LESIONS • Post inflammatory
hyperpigmentation
•- Tinea Corporis
•- Pityriasis rosea
•- Guttate psoriasis
investigations
• The diagnosis of P. Versicolor is usually made clinically on the basis of typical lesions
surmounted with scales.
• Culture of organism is of little value .
• 1. However the KOH wet mount test can be done Shows “Spaghetti and Meat ball”
appearance • Spaghetti represents the fungal hyphae of Malassezia • Meat ball represents
spore form
• Fig. KOH wet mount preparation of P. Versicolor
• 2. WOOD LAMP EXAMINATION
• On wood lamp examination of the lesion pityriasis versicolor gives the yellow fluroscence.
• Fig Wood Lamp Examination of lesion of Pityrasis versicolor
• 3. Histology  Not done usually but on histopathological examination shows the superficial
budding yeast (Blastoconidia) and short septate hyphae (Pseudomycelium) in stratum
corneum layer of skin.
• Wood lamp (black light) examination — yellow-green fluorescence may be
observed in affected areas
• Dermoscopy of pityriasis versicolor — pallor, background faint pigment
network, and scale
• Microscopy of a skin scraping (using potassium hydroxide (KOH) to
remove skin cells) — hyphae and yeast cells that resemble spaghetti and
meatballs
• Fungal culture — this is usually reported to be negative, as it is quite
difficult to persuade the yeasts to grow in a laboratory
• Skin biopsy — fungal elements may be seen within the outer cells of the
skin (stratum corneum) on histopathology. Special stains may be required.
TREATMENT
TOPICAL PREPARATION
• -Selenium sulphide
• -Zinc pyrithione
• -Sodium sulfacetamide
• -Azoles like Ketoconazole(2%),
• -Allylamines like Terbinafine (1%)
SYSTEMIC THERAPY
•- Ketoconazole (200mg OD for 7-10 days or SOD of 400 mg)
•- Fluconazole (Single oral dose of 400 mg)
•- Itraconazole (200-400 mg OD for 3-7 days)