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Referral and warning signs
When to refer
Refer if: Diagnosis uncertain. Extensive or refractory disease. Need for oral antifungal therapy.
Red flags
- Suspicion of other diagnoses (e.g., vitiligo, syphilis).
- Failure to respond to appropriate topical therapy.
Signs and symptoms
- Multiple, well-demarcated, oval macules and patches.
- Variable colour: Hypopigmented (white/pale), Hyperpigmented (brown/pink).
- Fine scale may be visible on scraping ('evoked scaling').
- Usually asymptomatic or mildly itchy.
- Common locations: Upper trunk (chest, back), neck, upper arms. Less common on face.
- More noticeable after sun exposure (affected areas don't tan).
Risk factors
- Warm, humid climate.
- Oily skin.
- Excessive sweating.
- Adolescence and young adulthood.
- Immunosuppression.
- Use of topical oils.
- Genetic predisposition.
Diagnosis
Clinical assessment
Diagnosis usually based on characteristic appearance and distribution of lesions.
Differential diagnosis
- Vitiligo (complete depigmentation, distinct borders, different sites).
- Pityriasis alba (hypopigmented patches, often face in children, less distinct borders).
- Seborrhoeic dermatitis (greasy scale, involves scalp, face, chest).
- Secondary syphilis (macular/papular rash, other systemic signs).
- Pityriasis rosea (herald patch, 'fir tree' distribution, usually self-limiting).
Investigations
- KOH Microscopy: Skin scrapings show characteristic 'spaghetti and meatballs' pattern (short hyphae and spores). Confirmatory.
- Wood's Lamp Examination: Affected areas may show yellow-green fluorescence (but not always reliable).
Diagnostic criteria
Clinical appearance +/- Confirmation by KOH microscopy.
Management
Non-pharmacological management
- Reassurance about benign nature.
- Avoid excessive heat/humidity if possible.
Pharmacological treatment
- Topical Antifungals (First-line): (LOC: HC2/3)
- - Antifungal Shampoos (used as body wash): Selenium sulfide 2.5% lotion/shampoo OR Ketoconazole 2% shampoo. Apply to affected areas, leave on for 5-10 minutes, then rinse. Use daily for 1-2 weeks, then weekly/monthly for maintenance/prevention.
- - Topical Azole Creams: Clotrimazole 1% or Miconazole 2% cream applied BID for 2-4 weeks.
- Oral Antifungals (For extensive, recurrent, or refractory cases): (LOC: HC3/4)
- - Fluconazole: 300mg PO once weekly for 2 weeks (UCG option) OR 150-400mg single dose.
- - Itraconazole: 200mg PO OD for 5-7 days.
- - Note: Griseofulvin is NOT effective against Malassezia yeast.
Monitoring
Monitor for clinical resolution. Pigment changes may take months to normalize even after successful treatment.
Complications
- Cosmetic concerns due to pigment changes.
- Recurrence is common.
- Folliculitis (Malassezia folliculitis).
Prevention
- Regular use of antifungal shampoo (e.g., weekly/monthly) can help prevent recurrence in susceptible individuals.
- Maintaining good hygiene, wearing breathable clothing.
Patient education
- Explanation of the condition as a common yeast overgrowth.
- How to use topical shampoos/creams correctly.
- Reassurance that pigment changes will resolve slowly over months.
- High likelihood of recurrence and need for maintenance therapy if prone.
- Griseofulvin does not work for this condition.
Uganda-specific notes
Very common due to climate. Often called 'Lugbara's disease' locally (referring to hypopigmentation). Topical azoles and antifungal shampoos (Ketoconazole/Selenium sulfide) are effective when available. Oral Fluconazole may be used for widespread cases.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 22, Section 22.3.1 (Tinea versicolor section)