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IMAGES IN CLINICAL MEDICINE. Tinea Versicolor.

A 24-year-old woman presented with a 12-year history of a depigmenting rash. The rash was most notable in the summer months, with remission during cooler seasons. She reported prominent scaling of her skin, particularly after showering. Over the preceding 2 to 3 years, the rash had spread to include her entire torso with extension down her arms. She was concerned that facial involvement might occur. Previous therapies with multiple topical antifungal agents had not regenerated skin pigmentation. Physical examination revealed large, coalescing, hypopigmented patches and macules on her torso and upper arms (Panel A) with scant scaling. A skin biopsy was performed to evaluate for vitiligo. Melan-A staining confirmed a normal presence of melanocytes (Panel B, arrows). Subsequent periodic acid–Schiff staining revealed the presence of yeast in a “spaghetti and meatball” pattern in the superficial epidermis (Panel C, arrow). A diagnosis of tinea versicolor was made. Scaling that results from stretching or scraping of the skin is suggestive of tinea versicolor and should prompt examination under the microscope, when possible, of skin scrapings treated with potassium hydroxide or chlorazol black E. Given the extensive skin involvement, the patient was treated with a course of oral fluconazole and topical ketoconazole; the patient was lost to follow-up. The process of skin repigmentation may take months once the fungal cause is eliminated.