Tinea Versicolor vs. Vitiligo

These two diseases produce skin changes.

• These two are very different diseases; vitiligo is an autoimmune skin disease that destroys the skin’s pigment-producing cells (melanocytes) while tinea versicolor results from superficial infection by a yeast, Malassezia furfur.
• These two diseases produce skin changes; vitiligo and its subtypes often first appear as a white spot on normally pigmented skin – it may begin with lightening of the skin’s pigment and progress to a loss of color, including whitening or graying of hair in the affected area. Tinea versicolor produces color variations in the skin; dark spots or red on light skin or patches of lightness on dark skin – “versicolor” means color variations.
• Both of these diseases may occur in many parts of the body, including the face.
• Neither of these two diseases is considered contagious; the yeast causing tinea versicolor usually arises from the patient’s own body flora.
• Tinea versicolor can produce itching and a red rash. It is predisposed to develop in areas of previous skin trauma, in contrast to vitiligo.
• Treatment for vitiligo and tenia versicolor are very different; vitiligo is often treated with topical steroids, psoralens, protopic ointment, and/or certain wavelengths of ultraviolet light and often, cosmetic coverage. In contrast, tinea versicolor is treated with antifungals (for example, miconazole, terbinafine, fluconazole, and over-the-counter dandruff shampoo, like Selsun Blue or Head and Shoulders).
• Vitiligo has no cure. Tinea versicolor may occasionally seem to be cured but, because the yeast is on the person’s body continually, it is not unusual to get recurrences, even after long time periods of symptomatic relapse.
• The prognosis of these diseases is good; while they may cause skin changes, most individuals with the problems have a normal lifespan.

Tinea Versicolor Symptoms

Discolored patches of skin are the hallmark of tinea versicolor. Versicolor means color variations, and characteristically it will appear dark or red on light skin, and light on dark skin. On the same patient, the appearance may vary over the course of the year depending upon whether the skin is winter pale or summer tanned. On the same patient, the appearance may vary with body location, being pink/brown on the mid back and pale on a tanned neck.

The rash is usually confined to shoulders, mid-back, and chest, but occasionally it will extend further down the arms. Facial involvement is only occasionally seen, usually in African-Americans and other darker-skinned patients.

Other skin findings such as severe itching, enlarging lumps, skin ulceration, hair loss, and swollen lymph nodes are not symptoms of tinea versicolor and should prompt a search for another diagnosis.

Vitiligo Symptoms

Classical vitiligo can begin any time after birth and often appears as a white spot without other symptoms on a background of normally pigmented skin. The only detectable change in affected areas is the loss of color, which can begin with lightening but will progress to complete loss of color. If vitiligo involves hair-bearing areas, it is not unusual to note the development of gray, pigment-free hair growing from involved follicles. There may be one or more of these patches that may gradually enlarge and rarely progress to involve the entire skin surface.

There are clinical subtypes of vitiligo that extend in a linear fashion down an entire limb (segmental vitiligo). Vitiligo often involves the genitalia and is predisposed to appear in areas of previous skin trauma. Obviously, completely depigmented skin can be much more cosmetically significant in those with racially darker pigmentation. Skin affected by vitiligo is particularly susceptible to sunburn and chronic sun damage.

Tinea Versicolor Causes

Malassezia furfur, a common human yeast carried by most people, can start to act more like tinea corporis (ringworm). While most people are never bothered by this yeast, it is also is felt to be responsible for dandruff (seborrhea), which explains why some of the treatments used for dandruff also help tinea versicolor.

Vitiligo Causes

There are poorly understood environmental factors that seem to interact with genes which predispose one to vitiligo. There are numerous theories as to the origin of vitiligo. A condition indistinguishable from vitiligo can be induced in some individuals after topical exposure to certain phenol-like chemicals.

Tinea Versicolor Treatment

Topical econazole (Spectazole), ciclopirox (Ciclodan), ketoconazole (Xolegel, Nizoral), clotrimazole (Lotrimin), and miconazole (Monistat) are all effective in treating tinea versicolor when applied until there is no further itching, scaling, or redness. Topical terbinafine (Lamisil) may be effective but may not work as well for yeast-related problems as it does for other fungal infections. Products that combine an antifungal with an exfoliating agent (Kerasal) or with an absorptive powder (Zeasorb) would be harder to use over a large area of the back and shoulders than a cream or spray.

Smaller areas of tinea versicolor may be treated with topical medications, but extensive involvement and recurrences are best treated with oral medications. The treatment course depends upon the medication chosen, but short and pulse-dose methods are effective at controlling the yeast. The discoloration will take much longer to resolve, and there is no reason to extend the treatment until clearance. Effective oral agents include ketoconazole (Nizoral), itraconazole (Sporonox), and fluconazole (Diflucan). Griseofulvin (Gris-peg) is not effective for yeast and should not be used.

Body washing with dandruff shampoos containing selenium sulfide (Selsun Blue), pyrithione zinc (Head & Shoulders, Soothe), and ketoconazole (Nizoral) may help the tinea versicolor clear faster and stay away longer. In the past, some have recommended application of shampoos for overnight use. These may be effective but are often very irritating to the skin. Zinc pyrithione-containing soaps (ZNP) may also be effective treatment.

Although the topical and oral medications described above are likely safe in pregnancy, many will prefer to try one of these body-washing treatments first. Pregnant women should talk to their doctor about treatment options.

Vitiligo Treatment

Treatment of vitiligo is dependent on its extent of involvement. It is unlikely that if more than 5%-10% of the skin is involved that topical therapy would be feasible.

Topical medical therapy generally involves the application of medications that inhibit the inflammation. Most commonly, potent topical steroids have been very useful in certain cases of limited vitiligo. Care must be taken to limit the use of such medications for a specific duration due to the side effects that stem from excessive use.

Another popular approach is the application of topical calcineurin inhibitor, tacrolimus (Protopic ointment) for example. These types of medications can have a beneficial effect and may be somewhat safer to use for long periods of time. The use of certain a certain types of lasers, the monochromatic excimer laser for example, which emit light in the UVB range (308 nm) can be effective.

In patients with more extensive disease, exposure to certain wavelengths of ultraviolet light can be effective (usually UVB light sources with outputs in the range of 290 nm-320 nm). Exposure to longer wavelengths of light in the UVA range (320 nm-400 nm) plus the ingestion of certain drugs called psoralens have induced pigment production in certain patients. Many exposures over a considerable period of time are often necessary to get optimal results. None of these treatments is likely to cure the basic problem, which can involve other areas of skin while the treated areas are improving.

Other options include cosmetic camouflages (Covermark or Dermablend), skin stains (artificial tanning chemical), and tattoos. In light-skinned individuals, avoiding the tanning of normally pigmented skin would decrease the contrast with vitiligo skin.

If a patient is unfortunate enough to become almost entirely depigmented, it may be cosmetically prudent to consider a medication, monobenzyl ether of hydroquinone, which is likely to destroy the few remaining melanocytes producing monochromatic white skin.

There are no universally effective treatments that work in all patients. When selecting a treatment plan, it is important to consider that most patients with vitiligo live normal healthy lives.

Tinea Versicolor Prognosis

The prognosis for tinea versicolor is good overall. Most patients will eventually "outgrow" tinea versicolor, but it may take decades. Although recovery of pale areas is delayed, even after systemic treatment, eventually they will repigment.

Vitiligo Prognosis

Generally limited vitiligo involving the face and trunk in children of recent onset is most responsive. Extensive disease in adults and disease affecting the hands and feet is resistant to therapy.