Perplexed by the sudden appearance of spots each spring or summer? Perhaps it's Tinea Versicolor . Often abbreviated as TV, this condition is due to a sudden overgrowth of a yeast ubiquitous to human skin.

The culprit, Malassezia furfur, is a yeast that grows on everyone's skin. M. furfur is not contagious and is typically an organism we never realize is there. So the condition is not contagious. For a creature found on 90-100 percent of adults, it's only a nuisance to some 2-8% of all Americans. However, since heat and humidity do play a role in developing this condition, Southerners are far more likely than Northerners to develop TV. And in some humid tropical countries, the rate of developing TV approaches fifty percent!

TV In Multi-Color

In keeping with the name versicolor, the eruption is most commonly characterized by an odd assortment of flat, scaling multi-hued creamy and brown patches, which polka dot the upper torso, shoulders, neckline and sometimes the lower face. Edges of the dime-sized patches may coalesce, merging into larger patches.

Sunlight makes the rash far more noticeable, explaining why so many TV patients seek out the dermatologist each summer. The yeast can stimulate melanosomes (packages of the skin pigment melanin) to be come larger. Once sunlight strikes the area, pigment darkens the affected portions of the skin. Imagine each polka dot tanning.

On the flip side, some patients suffer from lightening of the skin affected by the rash. While this is actually due to the M. furfur producing a skin-lightening acid, it is easy to visualize as a bad tan line. The skin around it darkens from getting tan, exaggerating the spots assaulted by a loss of pigment.

Two less common forms of the tinea versicolor rash exist. In patients who are immunocompromised, the rash may be "inverted", affecting nontraditional areas such as the face, extremities and flexures of the arms.

Finally, M. furfur can cause an infection of the skin surrounding the hair follicles of the torso, arms and legs. Difficult to differentiate from a bacterial infection of the hair follicles, it can appear as red bumps or pustules. A culture can rule out the diagnosis a bacterial infection. Patients who use steroids or antibiotics, are diabetic or receiving chemotherapy or live in a very humid climate may be more likely to experience this folliculitis.

Why Me?... Or Am I Going To Be A TV Dinner?

So now we know what it looks like, but why does it happen to just some of us? M. furfur is normally a "couch potato" type of normal flora. It's a yeast that simply hangs out on the skin minding its own business. In fact, in its routine state it is incapable of causing tinea versicolor. This yeast must literally change shape in order to be capable of causing a rash.

Tinea versicolor is not medically concerning or life threatening. In fact it is technically a "cosmetic" concern (unless you're the one suffering from it in which case it's a disaster). So calling the problem-causing form of the yeast "disease-causing" seems a stretch. Be that as it may, factors known to trigger the yeast to change into its "disease-causing" form include genetics, hot, humid weather, suppressed immunity (HIV, cancer, diabetes, etc.), malnutrition, steroid use and Cushing disease. But remember, the vast majority of people who develop TV are perfectly healthy.

Of course, everything needs sustenance and M. furfur is no different. It's not merely the form of the yeast that's problematic; it's the nutritional source to keep it thriving. That would be us.

Malassezia furfur is a lipid-loving yeast, thriving on areas of the skin rich in sebum such as the back and chest. Young adults between the ages of 15 and 24 have the highest levels of surface skin oils, and hence are more likely to suffer from TV. Prepubescent children don't make sebum and as one reaches menopause, sebum levels are also reduced. It is very uncommon to see tinea versicolor affect preteens or seniors.

It's been shown that is not the amount of sweat and sebum produced that triggers tinea versicolor. Rather, it's been suggested the yeast flourish because of something in the sebum. At one time it was thought that perhaps affected individuals produced sebum with higher lipid (fat) levels. Now the theory is that perhaps amino acids found in the sebum may factor into the conversion of the yeast into a form capable of causing the rash.

DIAGNOSIS

Diagnosis is usually quite obvious to the trained eye of the dermatologist. However, when in doubt, a microscopic test called a KOH is performed. This consists of the doctor painlessly performing a light skin scraping with a small blade. The scales are placed onto a glass slide, a droplet of liquid (potassium hydroxide) is placed onto the slide and then it is examined under the microscope. A positive test shows what we fondly call the "spaghetti and meatballs" sign under the microscope. Hyphae and spores from the yeast are both present and provide that creative appearance.

TREATMENT

PILLS

Sure, everyone would love to pop a pill and put an end to struggling with tinea versicolor once and for all. Ketoconazole (Nizoral), fluconazole (Diflucan), terbinafine (Lamisil) and itraconazole (Sporanox) are the preferred prescription oral medications. But the reality is that while the rash may clear, the medication doesn't prevent the inevitable recurrences.

Treatment is aimed at controlling the condition on a chronic basis. If we don't, the problem will likely come back. Ease of treatment is imperative as well as trying to keep it aesthetically pleasing.

ANTIFUNGAL CREAMS

Interestingly enough, although M. furfur is most commonly associated with tinea versicolor, it has been linked as a trigger factor with other common dermatologic concerns including seborrheic dermatitis (aka seborrhea or dandruff), psoriasis, perioral dermatitis and some forms of atopic dermatitis. That's why treatments for one disease can be beneficial for another.

Dermatologists have long turned to "off label" (not officially approved by the FDA) options to treat tinea versicolor. Part of this is that they simply work; the treaments are also easily available to patients who don't have access to physicians or must wait for an appointment. When consulting with such distinguished resources as the Merck Manual to the National Library of Medicine and NIH Medical Encyclopedia, lengthy lists of officially "off label", yet tried and true dermatologic therapies are listed for TV.

Lamisil Cream and Spray were once available only by prescription. At that time they carried the FDA indication for treating tinea versicolor. When the product went OTC Lamisil AT Continuous Spray for Athlete's Foot and Lamisil AT Cream - For Women, the indication was dropped. Likewise prescription Lotrimin is indicated for the treatment of tinea versicolor; OTC in the same strength, it is not.

Prescription 2% miconazole cream (Monistat-Derm) also carried the FDA indication for treating tinea versicolor. Again, now that 2 % miconazole is OTC, it no longer carries this indication.

Prescription creams available to treat TV include: Spectazole (Econazole Nitrate), Mentax (Butenafine Hydrochloride) and Oxistat (Oxiconazole Nitrate), Loprox (Ciclopirox) and Naftin (Naftifine Hydrochloride).

DANDRUFF SHAMPOOS

Dandruff shampoos are a longstanding favorite of ermatologists in TV therapy. Patients wash their bodies with dandruff shampoos that contain selenium sulfide, ketoconazole or pyrithione zinc once a day for 2 weeks. It is good to note that prescription Nizoral 2% Shampoo is indicated for treating tinea versicolor.

These active ingredients help kill yeast. Pyrithione zinc has been medically proven to kill the yeast that live upon the skin and drive this (and other) dermatologic conditions. Kill the yeast, clear the skin. Continued use creates an environment hostile to their regrowth and keeps skin looking clear and healthy.

Independent clinical trials results found DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser 100% as gentle, non-irritating and non-drying as Cetaphil Gentle Skin Cleanser. So no worries about drying or irritating the skin which is often seen when skin is washed with a dandruff bar or shampoo. It is an "off label" treatment that I recommend to my patients.

OIL CONTROL

This is an additional step to keep in mind for anyone prone to recalcitrant tinea versicolor. Reducing the amount of oil on the skin may help clear resistant TV. Try applying DERMAdoctor Tease Zone Oil Control Gel daily to affected areas. Cleansing with a glycolic acid cleanser to dissolve excessive torso oils such as DERMAdoctor Wrinkle Revenge Antioxidant Enhanced Glycolic Acid Facial Cleanser 1 or performing a home glycolic acid peel with MD Skincare Alpha Beta Daily Body Peel may also be helpful.

My favorite routine consists of the following "off label therapy":

• Wash in the shower with DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser soap daily for 2 weeks. If you prefer to use a bar soap, try ZNP Bar. Remember, if your skin is prone to being sensitive or dries out easily, you may prefer DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser.
• Towel dry.
• Apply an antifungal cream such as DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream or spritz with Lamisil AT Continuous Spray for Athlete's Foot. Make sure to treat the entire upper torso, arms and neck. Don't worry about trying to polka dot the rash, apply the cream to the entire general region. These were originally prescription items but are now OTC.
• Once a week on a maintenance basis wash with the DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser.
• Repeat your 2 week cycle anytime you note a recurrence as well as and when you know you will be getting more sun exposure. Typically this is every early spring and prior to tropical trips.

After the 2 week cycle is complete, the excessive amounts of yeast are gone. However, the "rash" isn't necessarily resolved. Much of the "rash" that people perceive is really skin discoloration. Just like having a bad tan line, it takes time for the skin tone to even out. You may help this along by avoiding getting the area exposed to sunlight. If you prevent a suntan, you will help to cut down on the exaggeration of the uneven discoloration.

Discoloration

Sunscreen is important. You need to wear an SPF 30 daily to prevent the dark spots from getting any darker in the sun, even if the yeast are long gone. I like using an oil-free (and preferrably oil-reducing) sunscreen such as DERMAdoctor Body Guard Exquisitely Light SPF 30 For Face & Body. This helps keep any moisture to a minimum that otherwise might help allow the yeast to grow. Normalizing the variation in skin tone may take as long as 6 months or so. This is a great reason to follow through with your preventative maintenance therapy. You don't really want to continually play catch up with skin discoloration. If you want to work on lightening the discoloration, consider DERMAdoctor Immaculate Correction Potent Hydroquinone-Free Skin Brightener or B. Kamins Skin Lightening Treatment. They can help lighten unwanted blotchy discoloration.

Don't worry about turning off your TV. Be positive. After all, tinea versicolor is definitely easily prevented and treated.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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