Review
Tinea Versieolor: Some New Aspects on Etiology,
Pathogenesis, and Treatment
JAN FAERCEMANN, M.D. AND TORSTEN FREDRIKSSON,
From the Department of Dermatology,
University Hospital Uppsala and
Central Hospital Vasteras, Sweden
Tinea versieolor is a superficial chronic fungal dis-
ease, characterized by lesions varying in color from red
to hypopigmentation to hyperpigmentation. The areas
usually involved are the upper trunk, neck, and upper
arms, although lesions may be found elsewhere on the
skin" vi'ith the exception of so-les and palms. The lesions
may be papular, numular, or confluent. Besides the main
complaint of cosmetic disfigurement, some patients also
note slight to moderately severe itching. Our knowledge
of the etiology and pathogenesis has increased signifi-
cantly, and new treatment modalities have been
developed.
Etiology
The fungal origin of tinea versieolor was suspected by
the middle of the last century,^~^ but was never really
proven until Gordon in 1951 isolated a lipophilic yeast-
like fungus from tinea versieolor lesions.* This fungus
fulfills the criteria for the genus Pityrosporum but dif-
fers in micromorphology from P. ovale, a species iso-
lated and characterized by Bizzozzero, Castellani, and
Chalmers in 1913.^ Gordon named the fungus P. orhicu-
lare because of its round form and classified it as a new
species of the genus Pityrosporum.'* He was able to cul-
ture P. orbiculare not only from tinea versieolor lesions
but even from normal skin in both patients with tinea
versieolor and healthy individuals.*-" P. orhiculare is
lipophilie and needs the addition of lipids to the eulture
medium for optimal growth.*-^-^ It grows well in the
temperature interval of 32-37 C, and at 37 C on a medium
Address for reprints: Jan Faergemann, M.D., Department of Der-
matology, Central Hospital S-721 89 Vasteras, Sweden.
0011-9059/82/0100/0008/$00.70 © International Society of Tropical Dermatology, Inc.
M.D.
that support optimal growth eolonies appear after three
days.** Solitary eolonies are slightly raised, round,
ereamy in eolor, and 4-6 mm in diameter. Miero-
seopieally, the eells are spherical, 3-6 /xm in diameter,
and many budding cells are present.^'* lt grows opti-
mally, not only in an aerobic but also in a micro-aero-
philic environment, and it can grow, although poorly,
even under strictly anaerobic conditions.^ In primary
cultures of P. orbiculare germ tubes are often
seen.*'^'^"" On routine media for subcultures it grows in
its saprophytic yeast form, but on specialized media or
under certain conditions filamentous forms can be pro-
duced.^•^•'^•'^ In adults P. orhiculare can be cultured not
only from patients with tinea vesicolor but also from
healthy individuals in 90-100%.*-^-^ We were unable
to culture P. orhiculare in children less than five years of
age but found it in the same incidence as in adults in
ehildren 15 years old.'* The low sebum production in
infaney and the faet that P. orhiculare is lipophilie may
explain the low ineidenee of this fungus in this age
period.'*
There are now many reports in favor of the identity of
P. orhiculare and the fungus seen in lesions of tinea
versieolor. Gordon was unable to produce experimental
infections with P. orhiculare in humans and on shaved
skin in rabbits.* In 1961 Burke produced tinea versieolor
with P. orhiculare in two patients with concomitant se-
vere disease, but the lesions were not evident until after
two to three weeks, and the inoeulation areas were not
strietly defined.*" We have earlier reported the sueeess-
ful production of tinea versicolor-like lesions with P. or-
hiculare in 10 patients with a past history of tinea ver-
sieolor and three healthy volunteers.'" The same elee-
tron mieroseopie morphology of P. orbiculare and the
fungus seen in tinea versieolor lesions has also been
described.'^''* Filamenteous forms resembling those
seen in tinea versieolor lesions have reeently been pro-
dueed by P. orhiculare in vitro.'''*-'^-" Antigenie
similarities between the two fungi have earlier been
No. 1 TINEA VERSICOLOR
found.'^ ^* In a study of antigenie similarities and differ-
enees in genus Pityrosporum, with pure IgG fractions
and using the indirect immunofluorescence (IIF) tech-
nique, we also found antigenie similarities between P.
orbiculare and the fungus seen in tinea versieolor (un-
published data).
The genus Pityrosporum includes, besides P. orbicu-
lare, P. ovale classified by Bizzozzero, Castellani, and
Chlamers in 1913^^ and P. pachydermatis classified by
Weidman in 1925.* P. Pachydermatis is non-lipophilic
and is primarily isolated from animals, although it has
been cultured from humans.^^ During recent years the
identity of P. orbiculare and P. ovale has been discussed.
P. ovale is also lipophilic and a member of the normal
human cutaneous flora.*"'''"'^^ P. ovale has previously
been associated with seborrheic dermatitis,^* and there
have been reports of the production of seborrheic der-
matitis like lesions with this fungus.^'^* The fungus de-
scribed in some of these reports^ could not later be iden-
tified as P. ovale, and today P. ovale is not regarded as
the etiological agent of seborrheic dermatitis."•^''•^"•^' In
culture no differences are observed in the macro-
morphology, and fermentation tests are negative in
both.* The micromorphology is quite different in P. or-
biculare and P. ova/e*'"-^* but there have been reports of
the change of P. orbiculare irom globose through ovoid
to cylindroid form.^*-^" P. orbiculare is constantly iso-
lated from tinea versieolor lesions but even P. ovale has
been cultured.^' We have recently been able to produce
macroscopically identical experimental infections in
both rabbits and humans with P. orbiculare and P. ovale
under plastic occlusion.* Microscopically we observed
the conversion between P. orbiculare and P. ovale, and
it was not always possible to observe any morphological
differences between specimens of P. orbiculare and P.
ovale, except that P. ovale cells were larger.* Antigenie
similarities between the two fungi have earlier been de-
scribed,^'-^^ and we also found identical results with
pure IgG fractions and the IIF-technique (unpublished
data), but in other reports antigenie differenees have
been found.'** Nazzaro Porro et al reported in 1977 the
production in vitro of identical hyphae in both P. orbicu-
lare and P. ovale with a mixture of cholesterol and
cholesterol esters added to the culture medium.'^ Dorn
and Rohnert were able to produce hyphae in vitro in P.
orbiculare but not in P. ovale, using a culture medium
containing glycine.'^ The identity of P. orbiculare and P.
ovale is thus not yet proven but in our opinion likely.
Pathogenesis
In tinea versieolor, under the influenee of pre-
disposing faetors, P. orbiculare (P. ovale) ehanges from
its saprophytie yeast form to its pathogenie mycelial
form. P. orbiculare produces in vitro dicarboxylic acids
Faergemann and Fredriksson
with a tyrosinase inhibitor effect.^^ Aside from a purely
inhibitory effect, the dicarboxylic acids may also have a
cytotoxic effect on the melanocytes and then by two
mechanisms be responsible for the hypopigmentation
seen in tinea versicolor.^^-^* In tinea versieolor P. orbicu-
lare is found not only extracellularly, in the stratum cor-
neum, but also intracellularly,^* and in the dermis an
inflammatory infiltrate of granulocytes and lymphocytes
is seen.^'^*'^" That P. orbiculare seldom is found in in-
fants may be one of the explanations to the low fre-
quency of tinea versieolor in these age groups.'* In
adults P. orbiculare is present on normal skin in 90-
100%, so the mere presence of P. orbiculare on the skin
is not correlated with tinea versieolor. The predisposing
factors responsible for the production of filaments in P.
orbiculare (P. ovale) are both exogenic and endogenic.
Tinea versieolor is more eommon in tropieal areas with
high temperature and high relative humidity sueh as
Samoa^^ and Liberia^* where almost half of the adult
population may be affeeted. A eontributing faetor may
also be that inhabitants in tropieal countries frequently
rub their bodies with palm oJIs or other lipid materials,
which may contribute to development of filaments. The
prevalence of tinea versieolor in countries with a temp-
erate climate is lower than in the tropics, but correct
information is difficult to obtain and mainly refers to
studies in patients seeking dermatological departments
for help. In Italy Caprilli et al found 3.7% with tinea
versicolor.^^ We found in an epidemiological survey of
tinea versieolor that 1.1% of new patients admitted to
the department suffered from tinea versieolor!*"
Tinea versieolor is limited to the seborrheie areas. In
the tropies where the temperature and humidity are
high, it is frequently seen in the faee.''^ In temperate
climate it is primarily located on seborrheic areas on the
trunk where cloth is occlusive and thereby a higher
temperature, humidity, and CO2 tension are produced.
Occlusion and CO2 are also predisposing in tine;a ver-
sieolor.*'
In a retrospeetive study of 232 patients with tinea
versieolor we found an assoeiation between tinea versi-
eolor and seborrheie dermatitis.*" Tinea versieolor was
three times more frequent than expected in patients with
seborrheic dermatitis, or 10.3%-of patients with tinea
versieolor had seborrheie dermatitis. In the eomplete
material the frequeney of seborrheie dermatitis was
3.8%. In a prospeetive survey oi; 48 patients with tinea
versieolor, five patients had seborrheie dermatitis
(10.4%) but here the same frequeney of psoriasis was
observed.*" An assoeiation between psoriasis and tinea
versieolor can be suspected from the frequent use of
greasy ointments in these patients. Tinea versieolor le-
sions are often diffieult to see in patients with psoriasis
where red nummulary lesions on the trunk may. be mis-
taken for nummular psoriasis. In these patients, the
10 INTERNATIONAL JOURNAL OE DERMATOLOGY
Wood's lamp is very helpful, and when screening all
psoriasis patients with this lamp we found several un-
suspected lesions (unpublished data).
Sohnle and Collins-Lech found a defect in production
of lymphokines in patients with tinea versieolor, and this
may be one of the main endogenic predisposing factors
responsible for tinea versieolor.*^ Other endogenie fae-
tors assoeiated with tinea versieolor are genetie fae-
{0^5 10,11 hyperhidrosis,'"'" systemie eortieosteroid ,
treatment,'"'" immunosuppressive treatment,*"-" and
malnutrition.•"•"
Treatment
Tinea versieolor is not a contagious disease. The con-
version of P. orbiculare to a pathogen depends upon
predisposing factors, and these may be difficult to eradi-
cate. This is the explanation for the difficult to perma-
nently cure patients with tinea versieolor and the reason
for its chronicity. That tinea versieolor is more eommon
in persons with poor hygiene is not true. Rigerous wash-
ing and scrubbing can make the diagnosis more difficult
so that only weak or absent fluorescence occurs with the
Wood's light, and even the microscopic diagnose can be
obscured. This will not cure tinea versieolor. If such pa-
tients with a high hygienic standard do not wash for two
to three days, the diagnosis is more readily confirmed.
There are numerous ways of treating tinea versieolor,
topically and recently also systemically*^"*®'*^ Whatever
aetive material in topieal preparations, we prefer to use
solutions or lathering vehieles sueh as shampoos and not
creams or ointments, since these are difficult to apply to
all affected body areas. We also prefer to treat the whole
trunk, neck, arms, and legs down to the knees even
when small areas are affected. Our present standard
treatment is using a selenium disulfide shampoo or a
zinc pyrithione shampoo. The patients are told to apply
the shampoo with an ordinary wet brush with a long
handle, work up a lather on all the mentioned areas, and
let it remain for a few minutes before showering. This is
repeated every evening for two weeks. We prefer the
zinc pyrithione shampoo, since it is very effective and
safe, cosmetically elegant and lacking the unpleasant
odor of selenium disulfide.*® In a double-blind compari-
son of the zinc pyrithione shampoo and its shampoo
base we had a 100% cure rate for the active shampoo
and none at all with the shampoo base (unpublished
data). The modern imidazole derivatives, such as
miconazole or elotrimazole, are certainly effective,**'**
but presently they are not generally available as sham-
poos. Therefore, if for some reason we find shampooing
unsuitable, we treat our patients with 50% propylene
glycol in water twice daily also for two weeks with ex-
cellent result and virtually without irritation.*' Propylene
glycol has good in vitro activity against P. orbiculare.*^ A
January-February 1982 Vol. 21
standard procedure is also to explain that the hypopig-
mented spots will persist for several weeks or months
even though the patient is "cured."
Ketoconazole, a new imidazole derivative for oral
use, seems also to be effective,*^ and in our ongoing
study the first 20 patients were all cured after three to
five weeks of treatment with ketoconazole 200 mg once
daily. It can be argued that an oral drug should not be
used in a benign disease where topical treatment is so
effective, but maybe it can be used prophylactically in a
low monthly dose. The main problem with this disease is
namely to avoid recurrence, and the frequency is very
high. In our material it is around 60% after one year and
80% after two years if precautions are not taken, like
using the zinc pyrithione shampoo one day every month
which also seems to reduce recurrence (unpublished
results).
Drug Names
clotrimazole: Lotrimin, Mycelex
ketocconazole: Nizoral
miconazole: Monistat derm
selenium disulfide: Exsel, losel, Selsun
zinc pyrithione: Breck One, DHS-zinc, Danex, Head and Shoulders,
Zincon
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No. 1 TINEA VERSICOLOR Faergemann and Fredriksson 11

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2:519, 1980

Kaposi's Sarcoma

Kaposi's sarcoma is rare in the United States, where the annual incidence is 0.021-0.061 per
100 000 population. In North America and Europe, this disease commonly presents as tumours of the
lower extremities, and the clinical picture is that of a localised disease with an indolent course. Most
patients are in their seventh decade. This form of the disease is commonest among Ashkenazi Jews
and those of Mediterranean origin, and especially in men.
The incidence of Kaposi's sarcoma in African Blacks residing in an endemic region is much higher
than among Blacks and Caucasians in North America and Europe. Kaposi's sarcoma makes up 9.1%
of all malignancies diagnosed in Uganda. In Africa, about 10% of patients with Kaposi's sarcoma
present with the lymphadenopathic form of the disease. They have few skin lesions, which may occur
on any part of the body, but extensive lymph node and visceral involvement. Most of the patients are
less than 20 years of age, and all reported cases have died within 3 years of presentation.
We describe here the features of Kaposi's sarcoma seen in eight young homosexual men in the New
York City area.—Hymes KB, et al: Kaposi's sarcoma in homosexual men—A report of eight cases.
Lancet ii:598, 1981