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Adolescent female presents with discoloration on her back and chest
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A 15-year-old female presents for her well-child visit. Her main concern involves discoloration of her back and chest that has been present for the past few months. She states she first noticed the discoloration during the summer when she became tan. Despite her tan fading, the “spots” have persisted. She denies improvement with regular application of her moisturizer to the areas. On physical examination, she has numerous 5 mm to 20 mm round and oval, slightly scaling hypopigmented macules and patches involving her back, neck, shoulders and chest.
Can you spot the rash?
Diagnosis: Tinea versicolor
Tinea versicolor (TV), also referred to as pityriasis versicolor, is a common benign skin condition often found in adolescents and young adults. Patients usually become aware of the condition in the summer when the affected skin does not tan. Several treatment options are available to patients, but the rate of recurrence tends to be high despite therapy.
TV is caused by a common dimorphic yeast, known as Malassezia furfur. Other Malassezia species may also be involved. Malassezia species are believed to be commensal organisms on the skin in the yeast form and thrive in a lipophilic environment. With clinical disease, the yeast converts to its hyphal form. Although sebum-producing cells contain low levels of lipid production in early childhood, they begin to produce lipid-rich sebum in early adolescence, which may explain the propensity to develop this condition during the teenage years. Besides adolescence, TV is seen more commonly with warm and humid weather, hyperhidrosis, application of oils, and with exposure to sunlight.
Marissa J. Perman
Images: Perman MJ
TV usually involves sebum-rich skin, including the trunk, neck and occasionally the face. Patients usually develop small, round or oval, hypopigmented and/or hyperpigmented lesions that may appear smooth or contain a fine white scale and tend to coalesce over time. Malassezia species produce lipases to metabolize fatty acids leading to metabolites, including azelaic acid. It is the azelaic acid that blocks the conversion of tyrosine to melanin and leads to the hypopigmentation. What leads to hyperpigmentation in certain patients is not known. Most patients are asymptomatic, but pruritus may be found in some patients.
Top photo: Numerous round and oval, hypopigmented, slightly scaling patches on the upper back. Bottom photo: Closer examination of individual lesions reveals a fine white scale.
Differential diagnosis
The differential diagnosis of TV includes pityriasis alba, pityriasis rosea, post-inflammatory hypo- or hyperpigmentation, seborrheic dermatitis and tinea corporis. When involving the trunk of an adolescent, progressive macular hypomelanosis of the trunk should also be considered. TV is clinically distinguishable by its distribution, fine scale and numerous lesions. Microscopic examination with potassium hydroxide reveals short hyphae and clusters of spores, known as “spaghetti and meatballs.”
There are many treatments available for TV. Most patients will respond to topical therapies, including selenium sulfide 2.5% lotion or shampoo; zinc pyrithione shampoo 1% daily for 1 to 2 weeks; or antifungal imidazoles such as ketoconazole cream twice daily for 2 to 4 weeks. However, recurrences are common.
For more extensive and recalcitrant cases, oral antifungal therapy has been used as a single dose, daily dosing for 1 to 2 weeks, or weekly dosing for 2 to 4 weeks. Oral azoles are not FDA approved for this indication in children.
TV is a common skin condition often seen in adolescents or young adults that can be unsightly. Most patients can be treated with topical therapies but should be warned of the high rate of recurrence and the benign nature of this condition.
References:
Hu SW. Arch Dermatol. 2010;146:1132-1140.For more information:
Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia. She can be reached at permanm@email.chop.edu.Disclosure: Perman reports no relevant financial disclosures.