Dr, Kiran Shrestha

1. PITYRIASIS VERSICOLOR
Dr. KIRAN SHRESTHA
(INTERN)
NMCTH,BIRGUNJ

2. INTRODUCTION
 Pityriasis versicolor is a mild chronic superficial fungal
infection of stratum corneum caused mainly by Malassezia
species.
 Infection usually results from change from its lipophilic
yeast form to mycelial form of Malassezia.
 Also called as ‘Tinea versicolor’ the term best discarded as
not caused by Dermatophytes.
 Malassezia species are normal flora of the skin and can be
cultured from both normal and affected skin.
 Also thought to be responsible for other dermatological
condition like Seborrheic dermatitis and is not contagious.

3. ETIOLOGY
 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
sympodalis and Malassezia furfur are predominant
species isolated in P. versicolor.
 Malassezia is naturally found on skin surfaces of many
animals including humans. It can be isolated in 18% of
infants and 90-100% of adults.

4. PATHOGENESIS
 Malassezia spp. are commonly found in the stratum corneum
of normal skin mostly around lipophilic zones like upper
trunk neck and upper arms in its yeast form
Under appropriate conditions
Warm, Humid environment
Hyperhidrosis(Sweating)
Oral Contraceptives, Steroids
Cushings Disease
Immunocompromised,
Malnourished state
Saprophytic Yeast cell
of Malassezia
converted into
parasitic mycelial form
which causes clinical
disease

5.  Malassezia metabolizes various fatty acids likearachidonic
acids or vaccenic acid via lipase and releases Azelic acids
which through inhibition of Tyrosinase in Melanin
production resulting in persistent hypopigmentation of
affected skin for months or sometimes years.
 Specific compound synthesized by Malassezia called
pityriacitrin that absorbs UV light and causes
hyperpigmentation.
 Other metabolites:
Malassezin : Induces apoptosis of melanocytes.
Pityrialactone : an indole alkaloids that fluroscences
under 300nm uv light
Pityriarubin : inhibits 5-lipoxygenase enzymes

6. CLINICAL PRESENTATION
 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 , powdery and branny.
 M/C site of lesions are on oily regions which are also
very sweaty like upper trunk often spreading to the
neck and upper arms.

7.  Lesion appears to be sitting on the skin.
 Lesion frequently coalesces to form patches but
the distinct perifollicular character of the lesions
invariably retained at periphery.
 Scratch sign: Lesion surmounted by branny scales
which can be accenuated by scratching lesion
gently with the help of glass slides 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.

8. Fig Perifollicular hypopigmented macules of P. versicolor

9. Fig. Lesion of Pityriasis versicolor

11. OTHER FORMS
 FORM 2 : Inverse Form
Distributed typically in flexular 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.

12. DIFFERENTIAL DIAGNOSIS
 Hypopigmented Lesions
 Vitiligo
 Pityriasis alba
 Leprosy
 Hyperpigmnted Lesions
 Tinea Corporis
 Pityriasis rosea
 Guttate psoriasis
 Nummular Eczema
 Confluent and Reticulate papillomatosis
 Post inflammatory hyperpigmentation

13. INVESTIGATIONS
 The Diagnosis of P. Versicolor is usually made clinically on
the basis of typical lesion 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

14. Fig. KOH wet mount preparation of P. Versicolor

15. 2. WOOD LAMP EXAMINATION
On wood lamp examination of the lesion pityriasis
versicolor gives the yellow fluroscence.

16. Fig Wood Lamp Examination of lesion of Pityrasis versicolor

17. 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.

18. 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)

19. PREVENTION
 TOPICAL OR ORAL TREATMENTS ARE USED FOR
PROPHYLAXIS IN CASE OF EXTENSIVE DISEASE.
Topical Ketoconazole, Zinc pyrithione or Selenium
sulphide shampoo applied 5-10 minutes , 1-4 times
monthly
Oral itraconazole 200 mg BD per month or
Fluconazole or Ketoconazole

20. PITYRIASIS ROSEA

21. INTRODUCTION
 Pityriasis Rosea is a papulosquamous rash usually affects teen and
young adults which is usually self limiting type of disease.
 Exact aetiology of this disorder remains to be unknown however a
virus HHV-7 more frequently and HHV-6 less frequently been
implicated in the pathogenesis of this disease though the disease is
non contagious.
 Probably related to respiratory infections and slightly more common
in females.
 Like other viral rashes most person will have this condition only once.

22. CLINICAL FEATURE
 Disease is characterized by initial appearance of
Herald’s patch followed by secondary lesions.
 HERALD’S PATCH
First lesion of Pityriasis Rosea and is seen in 80% of
patients.
Annular lesion with wrinkled salmon pink centre and
collarette of scales at the periphery.
Scales are just attached within leading edgeand free
towards the centre.
Primarily on trunks and upper arms.

23. FIG HERALD’S PATCH

24.  SECONDARY ERUPTIONS
 Begins as a scaly papules which enlarges to form
oval , annular plaques similar to Herald patch.
 These are smaller , less scaly and less
erythematous than Herald patch.
 Are arranged characteristically with the long axis
of patches runs downward and outward from spine
along the line of Ribs with Fir tree or Christmas
tree appearances.

25. FIG. FIR TREE DISTRIBUTION OF PITYRIASIS ROSEA

26. HERALD’s PATCH
Phase of evolution(1-2wks)
SIMILAR LESIONS, WHICH ENLARGES SLOWLY
Phase of resolution (2-10 wks)
MILD PIGMENTARY CHANGES
FADES SLOWLY
Fig. Pityriasis Rosea, Course A Self limiting Disease

27. HANGING CURTAIN SIGN
When invidual lesions are scratched along long axis
the scales tends to fold across the line of stretch.

28.  Atypical Variants
 Inverse Form : Secondary eruptions are usually
seen in Predominantly over axilla, groins
and neck.
 Papular Form : When secondary eruptions is
predominantly popular.
 Bullous Form : When secondary eruptions is
predominantly vesicular.

29. Differential diagnosis
 1. Tinea Corporis
 2. Secondary Syphilis
 3. Guttate Psoriasis
 4. Pityriasis Licheoides Chronica(PLC)
 5. Drug Eruptions
Like Gold, Captopril, Barbiturates, and
Penicillamines

30. INVESTIGATIONS
Usually no investigation is required, Pityriasis
Rosea is clinical diagnosis.
Serology to rule out Syphilis as it can closely
mimic secondary syphilis.
KOH wet mount to differentiate from fungal
infections.

31. TREATMENT
 Counsel patient regarding self limiting course of Disease.
 Symptomatic Treatment :
 Pruritus :Topical Calamine lotion and Antihistaminics
 Very Scaly/Erythematous Lesions: Coal Tar in Petroleum and
Low- Medium Potency Steroids
 Recalcitrant Lesions : Sunlight, PUVA/PUVA SOL

32. PITYRIASIS ALBA

33. INTRODUCTION
Often occurs on face, with chest being particularly common
site.
Etiology unknown maybe secondary to atopy and
postinflammatory changes.

34. EPIDEMIOLOGY
 Exact incidence not known upto 5% of children may have Pityriasis
alba.
 Prevalence : 5.2% in Nepal.
 Both gender equally affective.
 Age : 3-16 years of age.

35. CLINICAL FEATURES
 Rounded , Oval or Irregular plaques
 Red, Pink or Skin coloured
 Presence of Fine lamellar or Branny scaling
 Indistinct margins
 Usually 1-4 cm in diameter
 Generally asymptomatic but maybe mildly pruritic
 Site : often occurs on face , with cheek being
particularly common site.
 Most common age group 3-16 years of age

36. FIG. LESION OF PITYRIASIS ALBA

37. FIG. LESION OF PITYRIASIS ALBA

38.  Recurrent crops of new lesions may develop at
intervals with the duration of Pityriasis alba
varying from 1 month to 10 years . Most cases
however resolve over a period of several
months to years.

39.  UNCOMMON VARIANT
 PIGMENTING VARIETY
 EXTENSIVE VARIETY

40. Differential Diagnosis
 Vitiligo
 Leprosy
 Psoriasis
 Progressive and Extensive Hypomelanosis
 Nevus depigmentosus
 Hypopigmented Mycosis Fungoides
 Ash leaf Macules of Tuberous Sclerosis
 Atopic Dermatitis
 Tinea versicolor
 Medications such as Retinoic acids, Benzyl peroxide

41. INVESTIGATION
 Investigation to rule out other causes
 KOH wet mounts
 Wood’s Lamp : Vitiligo rash will glow more brightly and have edges
with sharper demarcation.
 SKIN BIOPSY
 Hyperkeratosis
 Parakeratosis
 Acanthosis
 Spongiosis
 Perivascular infiltrates

42. TREATMENT
 Reassurance
 Sun Protection
 Topical Steroids : For erythema and Pruritus.
 Bland Emolient creams to reduce scaling of the
lesions.
 PUVA in extensive cases.

43. References
 DERMATOLOGY AND SEXUALLY TRANSMITTED DISEASE – DR. NEENA KHANNA
 DERMATOLOGY IN GENERAL MEDICINE – FITZPATRICK’s
 MEDSCAPE