Efficacy of itraconazole in the treatment of tinea versicolor

Introduction

Tinea versicolor is caused by Malassezia furfur, the filamentous form of Pityrosporum orbiculare aye and P. ovale. Both are lipophilic members of the normal human cutaneous flora in the adult.[1]

Despite the use of numerous newer therapeutic regimens, TV has remained an enigma only because of recurrence and resistance of the yeast.[2] Itraconazole is newer orally active azole of the triazole series and the latest dimension to oral antifungal therapy with broad spectrum activity and favourable pharmacokinetic profile.[2],[3]

Itraconazole was tried to assess its efficacy in 20 patients with T versicolor who attended the department of Skin, STD and Leprosy, S.C.B. Medical College and Hospital, Cuttack.

Materials and Methods

Twenty adult patients (15 male, 5 female) with clinically diagnosed extensive TV. with duration of 6 months to 2 years were included in the trial.

Blood haemogram, LFT, RFT, were all normal. KOH smear was done and found positive in 15 cases. They were given itraconazole 100 mg orally twice daily for 5 to 7 days, for ten patients for 5 days and ten for 7 days. The patients were reviewed after 2 weeks and 4 weeks from the beginning of treatment and followed up for one year.

Results

Fifteen patients were males and five females. Their age varied from 17 to 55 years. Out of 20 patients one showed no change at all and 3 patients did not turn up. Parameters of clinical disease activity (itching, scaling, erythema, hypopigmentation and brownish colour or hyperpigmentation) were assessed and scored as 0 = none, 1 = mild, 2 = moderate, 3= severe. [Table - 1]

Out of 20, five patients did not complain of itching or irritation. Ten had mild to moderate itching and irritation, five patients presented with severe itching. Mild to moderate scaling was present in all the patients. Moderate erythema with hypopigmentation was present in 15, and five patients had a moderately brownish black pigmentation. KOH smear was positive in 15 patients.[Table - 2]

Two weeks after starting treatment, all the clinical features subsided in 60% of cases. After 3 weeks, scaling had disappeared in all the cases. All the features subsided in 80% of cases. KOH smear bacame negative in 60% of cases after the 2nd week, and in 80% of cases after the 4th week of treatment.

Discussion

In our study of 20 patients, itraconazole was effective in 60% of cases two weeks after treatment and in 80% of cases after three weeks.

Del Palacio Hernanz et al reported 82% of healing in their study group of 30 patients which is almost comparable with our result.[4] Scaling disappeared in all the cases after three weeks of treatment whereas itching and erythema with hypopigmentation subsided in 80% of cases. KOH smear was negative in 60% of cases after second week and in 80% of cases after 4th week of treatment. Hickman′s study showed a clinical cure rate of 89%, a little higher than our result, in 36 patients with 100mg itraconazole daily for 15 days.[5] Side effects like headache and gastrointestinal distress were very minimal, in 10% of cases. There was no recurrence during one year follow up.

These findings make the evaluation of treatment of pityriasis versicolor rather difficult. We could not depend on culture because it gives no definitive answer since pityrosporum sp lives on the skin of many normal people in a saprophytic form. KOH findings are not valid criteria to assess the efficacy of an orally active anti-fungal immediately after treatment since dead fungal elements remain on skin. Hypopigmentation also cannot be regarded as a primary symptom of the infection since the melanocytes need some time to recover even after disappearance of the fungus from the skin. However as topical treatment is time consuming and some topical preparations are greasy and have a bad odour, systemic therapy with itraconazole may be preferred. But to avoid high rate of relapse, prophylactic therapy should be mandatory. Its efficacy and safety should also be compared with double blind studies with alternative agents.