Abstract
Pityriasis versicolor is a persistent, superficial skin condition caused by various species of the commensal yeast Malassezia, most Commonly Malassezia globosa, but sometimes M. sympadialis Or M. furfur, It occurs in men and women and in different races. It is found more frequently in warmer, humid climates, and is usually more severe and persistent in the immunocompromised. It is characterized by scaly, oval macules on the upper trunk, Usually hypo pigmented but occasionally hyper pigmented. Hypopigmentation is more obvious after sun exposure and Tanning. The diagnosis can be confirmed by microscopy of Skin scrapings, showing ‘spaghetti and meatballs’ hyphae. Treatment with selenium sulphide or ketoconazole shampoos and Topical or systemic azole antifungal agents is usually effective, Although recurrence is common because these yeasts are skin commensals, and maintenance topical therapy may be Required. Altered pigmentation can persist for months after Treatment.
Keywords
Malassezia, Pitryrosporum, yeast, tinea versicolor, fungal infections, dermatoscopy, ultraviolet radiation, microscopy, confocal microscopy, imaging, treatment.
Introduction
Pityriasis versicolor (PV), also known as tinea versicolor, is a mild, non-contagious chronic, superficial fungal skin infection caused by lipid-dependent yeast-like fungus Malassezia.
It manifests as poorly to well-demarcated discolored or light pink scaly patches, usually affecting the trunk and arms. The disease occurs worldwide but is most prevalent in humid and warm tropical regions. PV tends to be more active in summer seasons.
Etiology
PV is a fungal infection caused by lipophilic yeast Malassezia (previously known as Pityrosporum) belonging to the Basidiomycota division and the Malasseziomycetes class.
The Malassezia genus, currently comprising 19 species, remains an integral component of the healthy skin microbiome.
M. Furfur, M. Globosa, and M. Sympodialis have been the most frequently isolated in PV .
On the other hand, M. Restricta and M. Globosa are by far the most abundant on human skin, whereas the other species occur less frequently .
Sebaceous areas of the human skin, including the scalp, face, chest, and upper back, remain a habitat for the Malassezia genus due to the abundance of a lipid nutrient source.
Epidemiology
No sex or ethnic predominance has been reported in PV .PV may affect persons of any age . Nevertheless, it most often develops in adolescents and young adults due to increased sebum production by the sebaceous glands, responsible for the lipid-rich environment, optimal for the yeasts. Higher incidence has been noted in physically active individuals, patients suffering from diabetes and obesity, and immunocompromised individuals. The disease occurs globally, but it is most commonly found in tropical regions and shows a higher incidence during the summer seasons. The prevalence of PV reaches up to 50% in tropical regions, whereas it is estimated to be around 1–4% and 1% in moderate and cold climates, respectively.[2]
Pathophysiology
- Malassezia is normally present on healthy skin,
- Primarily in oily regions like the face, scalp, and back.
- However, if it transforms into its pathogenic filamentous form, it can cause tinea versicolor.
- The precise elements in the host’s environment that trigger tinea versicolor still need to be clarified.
- Although experimental inoculations using topical oils and occlusion have proven successful,
- Tinea versicolor is not contagious.
- Poor hygiene is not a causative factor.
- Environmental factors like heat and humidity, pregnancy, oily skin, and applying oily lotions and creams increase the risk of tinea versicolor.
- Genetic predisposition and a hereditary component may play a role.
- A survey found that 21% of patients with tinea versicolor reported a positive family history.
- Immunocompromised individuals are at an increased risk of developing tinea versicolor, suggesting that an altered immune response in the host may play a role in the condition’s etiology.
- Malnutrition and the use of oral contraceptives may also act as risk factors.
- The word “versicolor” was coined to describe the condition because of the potential for alterations in cutaneous pigmentation.
- While the specific causes of pigmentary variation remain unknown, several hypotheses exist.
- The symptoms of hypo pigmented tinea versicolor, in which the skin does not darken in response to sun exposure, are generally most noticeable in the summer.
- Azelaic acid, a dicarboxylic acid generated by Malassezia, may have a role in the etiology of hypopigmentation due to its inhibitory or harmful actions on melanocytes.
Histopathology
A skin biopsy is not required to confirm the diagnosis. If the patient undergoes a skin biopsy, histological findings are hyperkeratosis, acanthosis, and a mild superficial, perivascular infiltrate in the dermis. Fungal elements primarily localize within the stratum corneum and are frequently observable in sections stained with hematoxylin-eosin.
Microscopically, using potassium hydroxide, short hyphae, and yeast cells are visualized in a pattern often likened to spaghetti and meatballs. Periodic acid-Schiff staining may improve recognition of the fungus. Hypo pigmented lesions typically contain fewer hyphae and spores than their hyperpigmented counterparts. In hypo pigmented lesions, the horny layer is typically mildly hyperkeratotic, and the stratum spinosum may contain fewer melanosomes.
Clinical Presentation
The characteristic feature of tinea versicolor is multiple, well-demarcated, oval, finely scaling patches or plaques.
Skin lesions may be hypo pigmented, hyperpigmented, or erythematous and occasionally become confluent and widespread.
Hyperpigmented tinea versicolor is typically a light brown in those with a fair complexion.
In patients with darkly pigmented skin, hyperpigmented tinea versicolor can manifest as macules and patches ranging from dark brown to grayish black.
Affected areas can vary in hue on the same person and can differ for people of the same skin tone.
The overlying scale may not be readily apparent on the lesions, but stretching or scraping the affected skin easily provokes it, known as the “evoked scale sign.”
Lesions that have been burned out or treated often lack scale.
The distribution of affected skin reflects the lipophilic nature of the fungus since the upper trunk and proximal arms are predominantly involved.
The face may also be affected, particularly in children.
Tinea versicolor skin lesions are usually asymptomatic or slightly pruritic.
However, severe pruritus can be present in hot and humid conditions.
Evaluation
The diagnosis of tinea versicolor can be made based on its characteristic clinical presentation of hyperpigmented or hypo pigmented, finely scaling patches or plaques.
If the symptoms are unclear diagnostically, dermoscopy and Wood’s lamp examinations may be helpful. A Wood’s lamp examination may help to demonstrate the gold-yellow, yellow-green, or coppery-orange fluorescence of tinea versicolor. Fluorescence is present in less than 50% of affected patients.
Common dermoscopic findings include a fine scale and a “contrast halo” sign, or ring of hypopigmentation surrounding the primary lesion of increased pigmentary network in a hyperpigmented lesion or a ring of increased pigmentation surrounding the primary lesion of decreased pigmentary network in a hypo pigmented lesion.
A microscopic examination of scales soaked in potassium hydroxide (KOH) provides a definitive diagnosis. The classic findings are grape-like clusters of yeast cells and long hyphae. Since the standard potassium-hydroxide mount lacks color contrast, methylene blue, ink blue, or Swartz-Medrik stain may be added for better visualization. Attempting to culture Malassezia species is known to be challenging, as they require fastidious culture conditions.
Treatment
Prior to treatment, inform patients that the causative agent of tinea versicolor is a commensal fungal inhabitant of the normal skin flora, and the disease is not contagious.
Also, pigmentary alterations frequently persist following successful treatment. Restoration of normal pigmentation may take months following treatment.
Medications- ketoconazole 2% Shampoo
selenium sulfide 2.25% to 2.5% shampoo or lotion applied for 10 minutes daily for 1 week
Topical 1% terbinafine once or twice daily from 1 to 4 weeks
Ciclopirox 1% applied twice daily for 2 weeks
Zinc pyrithione 1% daily for 5 minutes for 2 weeks
Another effective therapy is oral itraconazole 200 mg for 5 to 7 days.
Differential diagnosis
Seborrheic Dermatitis
Pityriasis Rosea
Erythrasma
Pityriasis Alba
Secondary Syphilis
Tinea Corporis
Vitiligo
Confluent reticulated papillomatosis of Gougerot and Carteaud
Prognosis
Oral and topical antifungal agents are effective; however, disease recurrence is common and may impact a patient’s quality of life. Preventive therapies are likely beneficial. Also, patients must be reminded that despite successful eradication, pigmentary changes may take weeks or months to clear. Some cases of spontaneous resolution occur, but if left untreated, the disease can be chronic.
Complication
Drug resistance, disease recurrence, or disease dissemination should prompt the consideration of an immunodeficient state. There have been reports of hair thinning and loss within tinea versicolor lesions. Most commonly, hair thinning or loss occurs on men’s forearms, abdomen, neck, and beard regions.[3]
Case summary
A 18 year old female
Presenting In OPD with following complains;
Hypo pigmented macules since 6 months
Itching sometimes with redness on scratching.
Location- nape of neck, upper trunk, upper thoracic region
Aggravation from cold air and summer sweating
Patient also complains of pain in lower extremities especially in heels with restlessness in feet since 2 months
Aggravation from cold air
Personal past history of;
Recurrent cystitis
Personal history
The patient belongs to a middle class family .
Anxious person
Occupation- 11th class student
Family history
Father- cholelithiasis
Mother- HTN
Physical general
Diet- 3 roti+sabzi+daal +chawal
Appetite- normal
Hunger tolerate
Thirst- thirst less
Micturition-normal
Bowel- normal
Perspiration- excessive and Offensive
Desire- salt and pickles
Sleep- disturbed
Dreams- frightful
Thermal – chilly
Mental general
The patient used to live in the village earlier, since she came to the city her friends went away, her house changed, she did not feel good, she used to stay alone in the house, her mother and father used to go to work, she felt lonely.
Carefulness
Emotions suppressed- She could not share her feelings with anyone
Fear of ghosts and evils
She takes full responsibility of household work after their mother and father go for a job and also study for herself.
Forgetful- because there is a lot of tension in his mind and she is overloaded with household chores.
Consolation aggravation
General examination
General condition- stable
Skin – oily
Lips- dry
Respiration- 18b/min
Pulse rate- 76b/min ,rhythm – regular, character and volume – normal
B.P.- 120/90 mm of Hg
Weight- 49kg
Height- 5’4”
Temperature- afebrile
Circulatory auscultation –s1 and s2 ++
Respiratory system- nasal passages( clear) and trachea ( In position)
Nervous system- well oriented and conscious
Rubrics
Remedy selection
On the basis of symptom Totality Sepia was prescribed .
Prescription on 14 oct 2024
Rx
Sepia 1M (SD), Sac lac 30 – tds- 15 days
Date and prescription
14 oct 2024- Sepia 1M (SD)
- Sac lac 30- tds- 15 days
29 oct 2024- sac lac 200- tds- 15 days
13 nov 2024- sepia 1M (SD)
-Sac lac 200 –tds- 15 days
28 nov 2024- Sac lac 200- tds- 15 days
13 dec 2024- Sac lac 200- tds- 15 days
1st visit- hypo pigmentation ( pictures below)
3rd visit- fading of white spots ( pictures below)
5th visit – clear off all spots (pictures below)
In this case, the patient who received homoeopathic treatment felt significant relief after 4 follow ups. Earlier, he had taken treatment at various places of different types but the relief in symptoms was not there. Homoeopathic treatment was given according to an individualistic approach.
I have seen many experienced doctors using high potency in such skin cases and have got results, and I too have seen many cases getting cured with high potency, on this basis I have selected high potency.
Remedy was selected on the basis of symptoms similarity
After analysing the reportorial totality.
Conclusion
Homeopathic medicines reduce both the intensity and frequency of pityriasis versicolor and help improve the patient’s quality of life. The instant case study demonstrates that individualised homoeopathic treatment is associated with significant relief in pityriasis versicolor.
Conflict of interest
Nil
Financial support
Not available
Reference
- Penman, I. D., Ralston, S. H., Strachan, M. W. J., & Hobson, R. (Eds.). (2022). Davidson’s principles and practice of medicine (24th ed.). Elsevier Health Sciences.
- Łabędź N, Navarrete-Dechent C, Kubisiak-Rzepczyk H, Bowszyc-Dmochowska M, Pogorzelska-Antkowiak A, Pietkiewicz P. Pityriasis versicolor-A narrative review on the diagnosis and management. Life (Basel) [Internet]. 2023;13(10):2097. Available from: http://dx.doi.org/10.3390/life13102097
- Karray M, Mckinney WP. Tinea versicolor. In StatPearls. StatPearls Publishing; 2025.
- Synthesis repertorium homeopathicum syntheticum edition 9.1
Schroyens F
B Jain, 2021 – Book
Author
Dr.Prathvi Kushwaha
Pg. scholar
Department- Practice of medicine
Batch- 2023-24
College- Govt. Homoeopathic Medical college and hospital
Bhopal ,Madhya Pradesh, India
Guided by-
Dr.Babita Saxena
H.O.D.
Department- gynae and Obstetrics
College- Govt.homoeopathic Medical College and Hospital Bhopal,
Madhya Pradesh, India
