Can Pityriasis Versicolor Be Treated With 2% Ketoconazole Foam?
July 2014 | Volume 13 | Issue 7 | 855 | Copyright © July 2014
Wendy C. Cantrell DNP CRNP and Boni E. Elewksi MD
Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL
Abstract
BACKGROUND: Pityriasis (tinea) versicolor is a superficial fungal infection of the stratum corneum caused by
Malassezia species. The
diagnosis is made clinically by its classic appearance of round or oval macules with fine scale that may be hyperpigmented or hypopigmented.
Diagnosis may also be confirmed with microscopic evaluation of skin scrapings that reveal both short, stubby hyphae, and
spores under KOH preparation. Ketoconazole is an important treatment of pityriasis versicolor but is primarily used in cream formulas.
A foam vehicle has been shown to improve drug absorption through the stratum corneum and distribution in the skin. This study has
assessed the safety and efficacy of ketoconazole 2% foam in treatment of pityriasis versicolor.
METHODS: Ketoconazole 2% foam was evaluated in a single-center, open-label, one-arm pilot study which enrolled eleven subjects to
gain 10 evaluable subjects aged 21 years and older with a clinical diagnosis of tinea versicolor and positive KOH using calcofluor. The
subjects came for 4 scheduled visits (baseline, week 1, week 2, and week 4) and were instructed to apply ketoconazole 2% foam to all
affected areas twice daily for 2 weeks. At each visit, mycological and clinical assessment of a target area was done, along with static
global assessment and body surface area estimation of the disease in each subject. Patient questionnaires were given at baseline and
at week 2 to rate pruritus and satisfaction with the foam.
RESULTS: At the week 2 visit, following the treatment period, three out of ten evaluable subjects had negative skin samples prepared
with KOH/calcifluor. Of these three, one subject later showed recurrence of fungal elements consistent with tinea versicolor at the
week 4 follow-up visit. The other negative subjects remained negative and four additional subjects tested negative at week 4. Three
subjects with positive samples at week 4 had only yeast forms without hyphae present. Investigator ratings of the target area were
averaged for each clinical feature and demonstrated improvement in scale, hyper- or hypopigmentation, erythema, and induration
throughout the study. Average pruritus score increased slightly 1 week after the baseline visit, but then improved steadily over the
remaining visits. The investigator’s static global assessment rating showed improvement from mild to moderate disease at baseline to
minimal or no disease at week 4 in 7 subjects. The remaining subjects showed neither improvement nor progression of the disease
throughout the study. One out of the eleven subjects enrolled did not complete the study. One subject noted mild skin burning sensation
after application of medicine. Post-treatment patient questionnaires indicated overall satisfaction with the foam vehicle.
LIMITATIONS: This was a single-arm, open-label, noncomparative trial.
Conclusion: Ketoconazole 2% foam improved overall clinical assessment and microscopic evidence of pityriasis versicolor in all subjects
with favorable patient feedback regarding the novel foam vehicle.
J Drugs Dermatol. 2014;13(7):855-859.
INTRODUCTION
Pityriasis versicolor, also known as tinea versicolor, is a
common superficial fungal infection caused by Malassezia
that affects the top layer of skin by causing well-demarcated
hypo- or hyperpigmented, round or oval macules with fine
scale. The lesions may be singular or may coalesce and most likely
present on trunk and upper arms, though some cases involving
scalp, face, neck, genitalia, axilla, finger webbing, and antecubital
fossa have been reported.1 Pityriasis versicolor may be found on
both men and women in areas all over the world, but in tropical
climates, up to 40% of the population could be effected.2 The
diagnosis is made clinically by its classic appearance and may be
confirmed by evaluating the mycology of skin scrapings prepared
with potassium hydroxide (KOH), which reveals both short, stubby
hyphae and budding yeast spores. Often described as “spaghetti
and meatballs†for its appearance under the microscope,1,3 Malassezia
is a lipophilic organism found in the skin’s outermost barrier,
the stratum corneum. Most species of Malassezia are a part of
normal skin flora, but as conditions become more favorable, the
organism evolves from the physiologic blastospore form into its
pathologic mycelial form.2 Favorable conditions include warmer
temperatures, increased humidity, immunodeficiency or immunocompromise,
elevated corticosteroids, pregnancy,4 and
malnourishment.5 These conditions generally cause increased
activity of sebaceous glands, which helps create the lipid-rich environment
needed for Malassezia to thrive. This quality seems to
explain why pityriasis versicolor, is rarely found in very young or
very elderly patients,2,6 but usually appears in “postpubertal and
mature ages when the sebaceous glands are most activeâ€.2
