Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Tinea Versicolor
A chronic, superficial fungal infection characterized by fine scaling and hypopigmentation or hyperpigmentation, mainly on the trunk.
I. Etiology: A superficial fungal infection caused by Malassezia furfur, a yeast-like fungus
II. Incidence
A. Seen most often in young adults in temperate zones
B. Uncommon prior to puberty
III. Subjective data
A. Slightly pruritic or asymptomatic
B. Chief complaint is cosmetic; patient complains of white, pink, or tan somewhat scaly spots on normal skin.
C. Often no complaints but found on routine physical examination
D. Generally a cosmetic complaint
IV. Objective data
A. Lesions
1. Maculosquamous or papulosquamous irregularly-shaped and circinate lesions that can be demonstrated by light scratching
2. Characteristically tan or reddish brown but may vary from white to brown
3. On skin exposed to the sun, lesions appear hypopigmented, because they do not tan. Lesions may be darker than surrounding skin in winter and lighter than surrounding skin in summer.
4. Areas may coalesce.
B. Distribution
1. Primarily on the trunk
2. Less commonly on the neck and face
V. Assessment
A. Diagnosis
1. Diagnosis is generally made by typical appearance of rash.
2. Microscopic examination of scales in potassium hydroxide fungal preparation reveals hyphae and budding yeasts.
3. Examination by Wood’s light: Lesions may show gold to orange fluorescence.
B. Differential diagnosis
1. Vitiligo: By family history; lesions pure white
2. Post-inflammatory or post-traumatic hypopigmentation: By history
3. Pityriasis rosea: Lesions oval with definite border; herald patch; acute onset
VI. Plan: Treat with one of the following:
A. Nizoral (ketoconazole) 2% Cream: Apply bid for 2 weeks. or
Exelderm Cream or Solution 1%: Apply gently bid for 3 weeks.
B. Selsun Lotion (Selenium sulfide) 2.5%; order 8 oz: Follow these steps daily for 7 to 14 days:
1. Bathe.
2. Rub lesions with a coarse towel.
3. Apply Selsun to entire trunk and other affected areas. (All lesions may not be apparent.)
4. Lather with a small amount of water.
5. Leave on skin for 10 minutes.
6. Rinse thoroughly.
C. Nizoral (Ketoconazole) 2% shampoo.
1. Apply to skin.
2. Leave on overnight.
3. Daily for 3 consecutive days.
D. Retin-A cream
1. Apply bid for 2 weeks.
2. Will lighten hyperpigmentation.
E. Frequent recurrences: Nizoral
1. 400 mg
2. Repeat dose in one week.
3. Do not order for adolescent females who may become pregnant.
VII. Education
A. Rub lesions with a coarse towel before applying medication.
B. Launder clothing, towels, and sheets in hot water.
C. Scaling should disappear within several days.
D. Continue treatment for several weeks. Tinea may persist for years with inadequate treatment.
E. Pigment changes resolve slowly. On sun-exposed skin, lesions will not appear normal until they acquire a tan or until existing tan fades; this may take 6 months.
F. Recurrence is common but can easily be treated.
G. Selsun may irritate skin.
H. Do not use Selsun on genitalia.
I. Nizoral is for adolescents and adults.
J. Relapse or reinfection is common.
VIII. Follow-up
A. Recheck in 2 weeks; scaling should not be present, but pigment changes will still be evident.
B. Recurrences should be retreated. If resistant to treatment, use Nizoral by mouth for 1 week.
IX. Complications: None; of cosmetic significance only
X. Consultation/referral: No improvement after skin color has had an opportunity to return to normal. (Repigmentation may take 3 to 6 months.)