Pediatric Dermatology Consult - November 2015

Oral antifungals such as itraconazole, fluconazole, and pramiconazole are effective for tinea versicolor, but have more adverse effects than topicals and interact with other medications because of their inhibition of the cytochrome P450 system, so they are used only for refractory or widespread disease.^1,11 In 2013, the Food and Drug Administration issued a black box warning against oral ketoconazole due its ability to cause life-threatening hepatotoxicity and adrenal insufficiency^1,23,24; it should not be used to treat tinea versicolor. Topical ketoconazole is safe and remains a first-line treatment for tinea versicolor, as discussed above.24 Oral terbinafine is not effective for tinea versicolor despite its efficacy as a topical treatment.¹¹

Patients with recurrent tinea versicolor can try preventive therapy with ketoconazole shampoo, zinc pyrithione shampoo, or selenium sulfide lotion or shampoo one to four times per month.1 Oral antifungals also are effective for prevention of recurrence, but should be used only if the condition is refractory to topical prophylaxis.^20,25 It is important to remember that hypopigmentation and hyperpigmentation may persist for months after resolution of active infection; absence of hyphae on skin scraping prepared with KOH confirms absence of active disease.^15,16 

References

1. BMJ. 2015;350:h1394. doi:10.1136/bmj.h1394.
2. Lancet. 2004 Sep 25-Oct 1;364(9440):1173-82.
3. Pediatr Dermatol. 1991;8(1):9-12.
4. J Eur Acad Dermatol Venereol. 2002;16(1):19-33.
5. Arch Dermatol. 2009;145(9):1078.
6. Vitiligo and other disorders of pigmentation, in: “Dermatology,” Vol 1. 3rd ed. (Philadelphia: Elsevier Saunders, 2012, pp.1041-2.)
7. Am J Clin Dermatol. 2000 Mar-Apr;1(2):75-80.
8. Mycoses. 1995;38(5-6):227-8.
9. “Skin Disorders Due to Fungi,” in: Hurwitz Clinical Pediatric Dermatology 4th ed. (Philadelphia: Saunders, 2011, pp. 396-403).
10. Infect Control Hosp Epidemiol. 2002 Apr;23(4):212-6.
11. Expert Opin Pharmacother. 2014 Aug;15(12):1707-13.
12. Clin Microbiol Rev. 2002 Jan;15(1):21-57.
13. Clin Dermatol. 2010 Mar 4;28(2):185-9.
14. J Am Acad Dermatol. 1994 Sep;31(3 Pt 2):S18-20.
15. Int J Dermatol. 2014 Feb;53(2):137-41
16. Mycopathologia. 2006 Dec;162(6):373-6.
17. J Invest Dermatol. 1978 Sep;71(3):205-8.
18. Int J Dermatol. 1992 Apr;31(4):253-6.
19. Pediatr Dermatol. 2000 Jan-Feb;17(1):68-9.
20. Arch Dermatol. 2010 Oct;146(10):1132-40.
21. Dermatology (Basel). 1997;194(1):22-4. doi:10.1159/000246179.
22. Red Book Plus: 2009 Report of the Committee on Infectious Disease.
23. https://www.fda.gov/Drugs/DrugSafety/ucm362415.htm    
24. J Cutan Med Surg. 2015 Jul-Aug;19(4):352-7.
25. Arch Dermatol. 2002 Jan;138(1):69-73.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego and professor of dermatology and pediatrics at the University of California, San Diego. Ms. Haddock is a medical student at the University of California, San Diego, and a research associate at the hospital. Dr. Eichenfield and Ms. Haddock said they have no relevant financial disclosures.

Email to pdnews@frontlinemedcom.com.