Itraconazole versus ketoconazole in the treatment of tinea versicolor

Pityriasis Versicolor Resistant to Antifungal Drugs in a Patient in Lomé (Togo)

Background

Pityriasis versicolor (PV) is a ubiquitous superficial skin mycosis that often affects young adults. It is often effectively treated with local or oral antifungal agents. Cases of PV resistance to antifungal agents have been reported rarely. We report a case of antifungal resistant PV. Observation. A 22-year-old patient was followed since the age of 17 years in a dermatology outpatient clinic for hyperpigmented scaly macular lesions of the trunk and upper limbs. The clinical diagnosis of PV was retained. The patient was treated by fluconazole 300 mg/week before being lost to follow-up. He was seen again in 2019 (about 2 years later) for the same symptomatology and treated again by fluconazole and ciclopirox olamine cream without improvement. He was again lost to follow-up and seen again six months later. A mycological sample was taken and Aspergillus niger was isolated. The patient was treated by itraconazole for 6 weeks. The evolution was marked by a clinical status quo. The patient was again put on salicylated petroleum jelly 10% associated with terbinafine cream and then lost to follow-up.

Conclusion

The emergence of fungal resistance to antifungal drugs does not spare PV. It can therefore be resistant to several antifungal drugs, leaving clinicians and patients in despair.

Antifungal Treatment for Pityriasis Versicolor

BACKGROUND

Pityriasis versicolor (PV), also known as tinea versicolor, is caused by Malassezia species. This condition is one of the most common superficial fungal infections worldwide, particularly in tropical climates. PV is difficult to cure and the chances for relapse or recurrent infections are high due to the presence of Malassezia in the normal skin flora. This review focuses on the clinical evidence supporting the efficacy of antifungal treatment for PV.

METHOD

A systematic review of literature from the PubMed database was conducted up to 30 September 2014. The search criteria were "(pityriasis versicolor OR tinea versicolor) AND treatment", with full text available and English language required.

CONCLUSIONS

Topical antifungal medications are the first-line treatment for PV, including zinc pyrithione, ketoconazole, and terbinafine. In cases of severe or recalcitrant PV, the oral antifungal medications itraconazole and fluconazole may be more appropriate, with pramiconazole a possible future option. Oral terbinafine is not effective in treating PV and oral ketoconazole should no longer be prescribed. Maintenance, or prophylactic, therapy may be useful in preventing recurrent infection; however, at this time, there is limited research evaluating the efficacy of prophylactic antifungal treatment.

Drug safety assessment of oral formulations of ketoconazole

INTRODUCTION

Ketoconazole was the first broad-spectrum oral antifungal approved by the FDA in 1981. Post-marketing reports of drug-related hepatotoxicity, endocrine dysregulation and drug interactions resulted in market withdrawal of the drug in some countries and strict product relabeling in others.

AREAS COVERED

This drug safety review summarizes reports of oral ketoconazole-related adverse events retrieved from a search of the PubMed database using the search strategy 'ketoconazole OR Nizoral AND hepat*', references from relevant publications, and data from the FDA Adverse Event Reporting System.

EXPERT OPINION

Although oral ketoconazole is effective in treating fungal infections, the potential for drug interactions, endocrine dysregulation, and hepatotoxicity may outweigh its benefits. Newer oral antifungals have similar or greater efficacy in treating dermatologic conditions and are associated with less risk. Likewise, newer agents with specific targets and fewer drug interactions have been developed to treat systemic fungal infections. Therefore, by the time ketoconazole prescribing guidelines were amended, its use had already largely been replaced with newer antifungals. Being that ketoconazole was the first broad-spectrum oral antifungal, experience with the drug made patient safety, and especially hepatic safety, an important consideration in future antifungal development.

Systematic Review of Systemic Treatments for Tinea Versicolor and Evidence-Based Dosing Regimen Recommendations

Background:

Extensive or recurrent tinea versicolor (TV) can be treated with systemic antifungal therapies, but no dosing regimens have been approved for this indication.

Objective:

To provide evidence-based recommendations for dosing regimens.

Methods:

A systematic literature search was performed to identify trials reporting mycologic cure. All trials were included and assessed for quality. Correlation and statistical analyses were used to evaluate the effects of different dosing regimen parameters on efficacy.

Results:

Fifty-seven trials investigating itraconazole, ketoconazole, fluconazole, and pramiconazole were included. Cumulative dose, treatment duration, and daily/weekly concentrations were shown to significantly influence mycologic cure rates for ketoconazole and pramiconazole but not for itraconazole and fluconazole.

Conclusion:

Based on the efficacy evidence and potential safety concerns, this review supports the following dosing regimens: 200 mg/d for 5 or 7 days of itraconazole, 300 mg/wk for 2 weeks of fluconazole, and 200 mg/d for 2 days of pramiconazole.

Pityriasis versicolor: quality of studies

OBJECTIVE

To evaluate the quality of the published literature on the treatment of pityriasis versicolor and to compare this evaluation with the number of times the work has been cited.

METHODS

A search was performed using MEDLINE (1966-2002) to find publications evaluating the treatment of pityriasis versicolor. Two reviewers evaluated each clinical trial according to a list of pre-determined criteria including randomization and blinding, prior sample size calculation, treatment regimen clearly explained, and well-defined efficacy parameters. A maximum score of 20 could be attained by each publication. A citation count was performed using the ISI Web of Science Database (http://www.isinet.com/isi/products/citation/wos/).

RESULTS

A total of 94 studies were included in this analysis of quality. Studies with a score of 8 or more were considered to be high quality, and 61 studies were rated as high-quality studies (65%). There was no significant correlation between paper quality and citation count.

CONCLUSION

It is important for investigators and clinicians to be aware of the design of a high-quality protocol, since such high-quality studies are more likely to reflect accurate efficacy rates. Also, it is important for the information on the design and conduct of the trial to be conveyed to the reader so that a meaningful comparison between the studies can be made.

Optimal management of fungal infections of the skin, hair, and nails

Superficial fungal infections are chronic and recurring conditions. Tinea capitis is a scalp infection, primarily affecting prepubescent children. Ringworm infections, such as tinea corporis and tinea cruris, involve the glabrous skin. Tinea nigra is a rare mycotic infection that may be related to travel abroad. Piedra, black or white, is limited to the hair shaft without involvement of the adjacent skin. Pityriasis (tinea) versicolor and seborrheic dermatitis are dermatoses associated with yeasts of the genus Malassezia that affect the lipid-rich areas of the body. The taxonomy of the Malassezia yeasts has been revised to include nine species, eight of which have been recovered from humans. Tinea pedis, an infection of the feet and toes, is one of the most common forms of dermatophytosis. Onychomycosis is a fungal infection affecting the nail bed and nail plate; it may be chronic and can be difficult to treat. In instances where the superficial fungal infection is severe or chronic, an oral antifungal agent should be considered. Terbinafine, itraconazole, and fluconazole are oral antifungals that are effective in the treatment of superficial mycoses.

Superficial fungal infections: an update on pityriasis versicolor, seborrheic dermatitis, tinea capitis, and onychomycosis

The recent advances in pityriasis versicolor, seborrheic dermatitis, tinea capitis and onychomycosis are reviewed. Some highlighted points include the new classification of Malassezia species, and the association of Malassezia species with seborrheic dermatitis. The use of terbinafine, fluconazole, and itraconazole for the treatment of tinea capitis is discussed. The management of onychomycosis, highlighting the high efficacy rates obtained with terbinafine when used to treat dermatophyte toenail onychomycosis, is discussed. The use of combination therapies in some circumstances to maximize cure rates is reviewed.

Pityriasis versicolor

Pityriasis versicolor is a mild or chronic condition characterized by scaly hypopigmented or hyperpigmented lesions usually affecting the trunk. The lesions vary depending on tropical or temperate climates. The disease seems to occur mainly at adolescence when the sebaceous glands are more active. Malassezia yeasts have been implicated in the pathogenesis of this disease. The mycelial form of the fungus has been suggested to be the cause of lesions. Antifungal preparations have been used to treat the initial presentation effectively, although in a proportion of patients the disease tends to reoccur. They are available in a wide range of formulations and have been shown to be safe.

Fluconazole versus ketoconazole in the treatment of tinea versicolor

BACKGROUND

A number of effective topical therapies are available for the treatment of tinea versicolor (TV). However, topical antifungals are difficult to apply to a large body surface area and for this reason TV is perhaps more easily treated with systemic agents.

METHODS

A total of 128 patients with TV, aged 15-55 years, were entered into a randomized, double-blind, clinical trial comparing the efficacy and tolerance of two regimens of oral treatment for TV. The patients were randomly divided in two groups: group 1 received two 150 mg capsules of fluconazole in a single dose repeated weekly for 2 weeks; and group 2 received two 200 mg tablets of ketoconazole in a single dose repeated weekly for 2 weeks. Diagnosis of TV was made clinically by direct KOH preparation and Wood's lamp examination.

RESULTS

Of 128 patients, 100 completed the study and no major side-effects were noted between the two treatment regimens. Results of the study showed no significant differences in efficacy, safety and tolerability between the two treatment regimens. The maximal cure rate was achieved at 8 weeks from the start of treatment and decreased slightly afterwards.

CONCLUSIONS

Fluconazole and ketoconazole demonstrated similar efficacy in the treatment of TV. We also demonstrated a lack of correlation between mycological cure and hypopigmentation at the end of treatment (2 weeks) and the usefulness of Wood's lamp examination in detecting cure of TV.

Comparison of a single 400 mg dose versus a 7-day 200 mg daily dose of itraconazole in the treatment of tinea versicolor

BACKGROUND

Tinea (pityriasis) versicolor is a superficial infection of the stratum corneum by the lipophilic fungus known as Malassezia furfur.

OBJECTIVE

To evaluate the efficacy and safety of a 400 mg single dose or 7-day 200 mg daily dose of itraconazole capsules in the treatment of mycologically confirmed pityriasis versicolor.

METHODS

A total of 50 patients were entered into a randomized, open, clinical trial comparing a 400 mg single dose (n = 24 for group 1) with a 7-day 200 mg daily dose (n = 26 for group 2) of itraconazole. Clinical signs and symptoms and mycologic evaluation (potassium hydroxide preparation and Wood's lamp) were performed before treatment, and at weeks 3 and 6 after treatment.

RESULTS

Both regimens of itraconazole were effective. Our results showed that there were no significant differences in efficacy and safety between the two treatment regimens (chi-square tests, p > 0.05).

CONCLUSIONS

On the basis of these findings, a single dose of itraconazole 400 mg/day was as effective as the 7-day 200 mg daily dose in the treatment of pityriasis versicolor.

Pityriasis versicolor

Pityriasis versicolor is a common superficial fungal infection of the skin. It is caused by Malassezia spp., which are normal human saprophytes. Under certain conditions, both exogenous and endogenous, the fungus can convert from a yeast to a pathogenic mycelial form. This alteration results in mild inflammation of the skin, and in characteristic clinical and histological changes. The taxonomy of Malassezia spp. has recently been modified to include six obligatorily lipophilic species, all of which can be found on human skin, plus one non-obligatorily lipophilic species, which only rarely colonizes human hosts.

LEARNING OBJECTIVES

At the conclusion of this learning activity, participants should be aware of the role of Malassezia in the development of pityriasis versicolor, the clinical and histological changes arising from this dermatosis, and the diagnosis and treatment of this disorder.

Management of seborrheic dermatitis and pityriasis versicolor

Pityriasis (tinea) versicolor and seborrheic dermatitis are two very common skin diseases. Pityriasis versicolor is a chronic superficial fungal disease usually located on the upper trunk, neck, or upper arms. In pityriasis versicolor, the lipophilic yeast Malassezia (also know as Pityrosporum ovale or P. orbiculare) changes from the blastospore form to the mycelial form under the influence of predisposing factors. The most important exogenous factors are high temperatures and a high relative humidity which probably explain why pityriasis versicolor is more common in the tropics. The most important endogenous factors are greasy skin, hyperhidrosis, hereditary factors, corticosteroid treatment and immunodeficiency. There are many ways of treating pityriasis versicolor topically. Options include propylene glycol, ketoconazole shampoo, zinc pyrithione shampoo, ciclopiroxamine, selenium sulfide, and topical antifungals. In difficult cases, short term treatment with fluconazole or itraconazole is effective and well tolerated. To avoid recurrence a prophylactic treatment regimen is mandatory. Seborrheic dermatitis is characterized by red scaly lesions predominantly located on the scalp, face and upper trunk. There are now many studies indicating that Malassezia plays an important role in this condition. Even a normal number of Malassezia will start an inflammatory reaction. Mild corticosteroids are effective in the treatment of seborrheic dermatitis. However, the disease recurs quickly, often within just a few days. Antifungal therapy is effective in the treatment of seborrheic dermatitis and, because it reduces the number of Malassezia, the time to recurrence is increased compared with treatment with corticosteroids. Antifungal therapy should be the primary treatment of this disease.