Oral fluconazole in tinea versicolor

Tinea versicolor (TV) is a common superficial fungal disease caused by a lipophilic yeast-like organism, Pityrosporum orbiculare (Malassezia furfur).[1]

There are numerous ways of treating TV topically and systemically. Many topical agents have been used with limited success because of objectionable odour, messy application, require frequent application and prolonged treatment time. These agents have also been associated with high recurrence rate. At present the oral agents available for the treatment of TV are ketoconazole, itraconazole and fluconazole. Patients find oral treatment acceptable, but in - view of side effects of ketoconzole certain degree of hesitation continues to exist about the oral treatment of TV.[2] The introduction of oral fluconazole, a bistriazole with broad spectrum of activity, offered an effective and easily administered alternative treatment. It is active in vitro and in vivo against dermatophytes, yeasts and various other fungi. Experience with oral fluconazole in the treatment of TV is relatively limited.

Subjects and Methods

Twenty-five patients with recurrent and / or extensive TV, confirmed by direct microscopy (KOH) were included in the study. The criteria for selection of cases were, extensive involvement, long duration, poor response to previous topical treatment and frequent recurrences. Patients below 12 years of age, pregnant women and patients who had history of jaundice in the recent past and history of alcoholism were excluded. All patients were given a single dose of 400mg fluconazole orally. The patients were asked to report for follow up at the end of 3 weeks, 6 weeks and 8 weeks. Possible signs of side effects were recorded. Clinical and mycological responses were recorded as follows.

Clincal evaluation was done by the naked eye appearanc of the lesions, presence of repigmentation and disappearance of the lesions. The following criteria was adopted for this.

+/- : No improvement: Persistance of lesions and presence of scaling.

+/- : Slight improvement : Lesions were less prominent and / or moderate decrease in scaling.

+ +/- : Marked improvement : Lesions appeared pale with presence / or absence of mild scaling and disappearance of some of the lesions

+ + +/- : Complete clinical cure : Complete disappearance of lesions.

Mycological evaluation was done by examination of fungal scrapings at the end of 3rd, 6th and 8th week. Negative KOH was considered as cure. Routine blood, urine and stool examination were done in all cases. No other systemic or topical antimycotic agents were allowed during the study.

Results

Twenty-five patients returned for follow-up at the end of third week, 6th week and 8th week after treatment. A clinical cure of 100% was observed in the third week of this study. No clinical relapse was observed during follow-up (6th week and 8th week). Mycological cure of 100% was observed at 3rd and 6th week of follow up. However, in 8% of cases mycological relapse was seen at the end of 8 weeks. No side effects were observed.

Discussion

In the present study, short term oral treatment with a single dose of 400mg of fluconazole was very effective and the majority of the patients found the treatment effective, convenient and safe. Follow-up at 3 weeks, 6 weeks and 8 weeks showed 100% clinical cure. This correlates well with the study of Shah.[3] According to the study by Faergemann,[4] clinical cure rate of only 74% was reported. At the end of 8 weeks 2 patients showed mycological relapse. The mycological relapse after treatment has also been observed with other systemic antifungal agents.[5] The fast reappearance of P ovale after therapy is probably one explanation for the high rate of relapse. To avoid this, prophylactic therapy will be mandatory. Though total eradication was not possible, from the clinical point of view, fluconazole appeared to be a better choice in the treatment of the TV in comparison to most other systemic therapies.