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Infections and infestations Skin and nail

Pityriasis versicolor

Last revised in March 2025

Pityriasis versicolor (also known as tinea versicolor) is a common fungal infection of the skin that is localized to the stratum corneum.

Pityriasis versicolor: Summary

  • Pityriasis versicolor (also known as tinea versicolor) is a common chronic fungal infection of the skin caused by Malassezia species, localized to the outermost layer of the epidermis. 
  • Pityriasis versicolor occurs worldwide but prevalence varies with location — it is more common in hot and humid climates, and in temperate zones it occurs more often in the summer than in the winter months.
    • It is rare in childhood but is more common in the late teens.
  • Spontaneous remission without treatment is unusual. With treatment, prognosis is good.
  • Diagnosis is usually made on the basis of clinical features alone.
    • Pityriasis versicolor is characterized by multiple round or oval macules and confluent patches that most commonly occur on sebum-rich areas of the skin, particularly the upper trunk, upper arms, neck and abdomen. 
    • The colour of lesions varies and can be fawn, pink, red, brown, black, or almost white — the surface of patches usually has a fine scale (which may be subtle).
    • People with darker skin tone may present solely with hypopigmented lesions.
    • Macules and patches are usually asymptomatic, but mild itch sometimes occurs.
  • Diagnosis can be confirmed by microscopy of skin scrapings, although this is not usually necessary.
  • Disorders that may present similarly include vitiligo, psoriasis, tinea corporis, seborrhoeic dermatitis, pityriasis rosea, erythrasma, and secondary syphilis.
  • Initial management of pityriasis versicolor involves the use of a topical antifungal shampoo or cream.
    • Ketoconazole 2% shampoo (once a day for 5 days) is recommended. 
    • For small areas an antifungal cream (such as clotrimazole) can be used.
  • If pityriasis versicolor is extensive, or if topical treatment is ineffective:
    • An oral antifungal drug (such as itraconazole or fluconazole) may be considered in non-pregnant adults.
    • Children and pregnant/breastfeeding women should be referred to dermatology for specialist management.
  • Changes in skin pigmentation usually fully resolve within several weeks to months of starting antifungal treatment (but may persist for years).
  • Relapse is common and in most cases re-treatment of each episode as for the initial presentation is appropriate.
    • Alternatively, ketoconazole shampoo can be applied once every 1–4 weeks to reduce the risk of recurrence.
    • If episodes of pityriasis versicolor recur on exposure to warm, humid environments or sunshine, prophylactic treatment with ketoconazole 2% shampoo once daily for a maximum of 3 days prior to exposure (for example before travel abroad) can be considered.

Have I got the right topic?

From age 10 years onwards.

This CKS topic covers the management of pityriasis versicolor, also known as tinea versicolor.

This CKS topic does not cover the management of other fungal infections of the skin.

There are separate CKS topics on Fungal nail infection, Fungal skin infection - body and groin , Fungal skin infection - foot, Fungal skin infection - scalp, Psoriasis, Pityriasis rosea, Seborrhoeic dermatitis, and Vitiligo.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

March 2025 — reviewed. A literature search was conducted in February 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.

Previous changes

October 2023 — minor update. Information added that the manufacturers of fluconazole advise a washout period of approximately 1 week (5-6 half-lives) before becoming pregnant, in line with the updated summary of product characteristics.

July 2022 — minor update. Added drug interaction between clotrimazole and tacrolimus.

March to April 2020 — reviewed. A literature search was conducted in February 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

November to December 2015 — reviewed. A literature search was conducted in November 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made.

February 2011 — minor update. Suggested regimen for preventing recurrence of pityriasis versicolor corrected to ketoconazole shampoo. 

July to November 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analyses which reach the CKS threshold for inclusion since 1 March 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2025.

New policies

No new national policies or guidelines since 1 March 2025.

New safety alerts

No new safety alerts since 1 March 2025.

Changes in product availability

No changes in product availability since 1 March 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of pityriasis versicolor.
  • Manage pityriasis versicolor appropriately in primary care.
  • Provide advice on how to prevent recurrence of pityriasis versicolor.
  • Refer to dermatology where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Pityriasis versicolor (also known as tinea versicolor) is a common fungal infection of the skin, caused by Malassezia species, localized to the outermost layer of the epidermis (the stratum corneum).  
  • It is characterised by discreet or confluent macules that have a fine powdery scale. Lesions may be hypopigmented or hyperpigmented, and vary in colour (pink, fawn, red, brown, black, or white). People with dark skin may present solely with hypopigmented lesions.   

[Gupta, 2002; Gupta, 2004; Schwartz, 2004; Kallini, 2014; Gupta, 2015; UKHSA, 2016; Hay, 2024]

What causes it?

  • Pityriasis versicolor is caused by Malassezia yeasts that are part of the normal skin flora in 90–100% of people.
    • The most common species isolated from cases of pityriasis versicolor is Malassezia globosa. Malassezia sympodialis and Malassezia furfur have also been identified.
    • The yeasts are obligatorily lipophilic (that is, they require the presence of lipids to grow). 
    • Colonisation is most dense in areas rich in sebaceous glands such as the trunk, head, neck and upper arms. 
    • Infection occurs when the Malassezia yeasts switch from a saprophytic to a mycelial form.
  • Conditions that favour proliferation of the pathological form of the Malassezia yeast include:
    • Warm, humid environments. 
    • Hyperhidrosis (excessive sweating). 
    • Occlusion of skin with creams or lotions.
    • Malnutrition. 
    • Immunodeficiency (for example, due to diabetes mellitus or Cushing’s disease) or immunosuppression (with oral corticosteroids or other immunosuppressive drugs). 
    • Use of oral contraceptives.

[Gupta, 2002; Schwartz, 2004; Gupta, 2015; Hald, 2015; UKHSA, 2016; Leung, 2022; Hay, 2024]

How common is it?

  • Pityriasis versicolor occurs worldwide but prevalence varies with location — it is most common in hot and humid climates [Gupta, 2015; Hald, 2015; Leung, 2022; Hay, 2024].
    • In temperate zones it occurs more often in the warmer months of the year, or after travel to a warmer climate.
    • In some tropical countries, the prevalence is as high as 50%, whereas in Sweden, the prevalence is as low as 0.5%. 
  • It is most common in teenagers and young adults with a peak in the early twenties (when the sebaceous glands are more active), and is rare in young children and older adults [Gupta, 2002; Hay, 2024].

What is the prognosis?

  • Pityriasis versicolor is a chronic infection — spontaneous remission without treatment is unusual, but with treatment prognosis is good. 
  • Mycological cure is usually achieved soon after antifungal treatment, although pigmentary changes may take several weeks to resolve, but can persist for months to years.
  • Recurrence is common (especially in warmer climates) and can be as high as 80% within 2 years. 

[Gupta, 2002; Schwartz, 2004; Gupta, 2015; Leung, 2022; Hay, 2024]

Diagnosis of pityriasis versicolor

When should I suspect pityriasis versicolor?

  • The diagnosis is usually made on clinical features alone.
  • Multiple round or oval macules and confluent patches are commonly seen.
    • Patches are usually asymptomatic, but mild itch sometimes occurs.
    • The colour of lesions varies and can be pink, fawn, red, brown, black, or white  — the surface of patches usually has a fine scale (which may be subtle).
      • Lesions often appear hyperpigmented on lighter skin types and hypopigmented in darker or tanned skin. 
      • In people with lighter skin lesions may be more noticeable in the summer months if patches fail to tan.
      • In people with darker skin hyperpigmented lesions may present as dark brown to grey–black macules and patches, but they may present solely with hypopigmented lesions.
    • Pityriasis versicolor most commonly occurs on sebum-rich areas of the skin, particularly the upper trunk, often with spread to the upper arms, neck, and abdomen. Other areas that may be affected include the axillae, face, groin, thighs, scalp, and genitalia. 
  • On Wood's light examination lesions may fluoresce a bright gold-yellow, yellowish-green or coppery-orange, although some lesions do not fluoresce. 
  • Laboratory testing with skin scrapings is not usually required for diagnosis.
    • Skin scrapings may be considered if the diagnosis is uncertain or initial treatment in primary care has failed — for more information, see the section on treatment failure. 

Basis for recommendation

These recommendations are based on Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases [Hald, 2015], expert opinion in a dermatology textbook [Hay, 2024], and narrative reviews Pityriasis versicolor [Gupta, 2002], Skin diseases associated with Malassezia species [Gupta, 2004], Antifungal treatment for pityriasis versicolor [Gupta, 2015], Tinea versicolor: an updated review [Leung, 2022], Superficial fungal infections [Schwartz, 2004], and Tinea versicolor in dark-skinned individuals [Kallini, 2014].  

Skin scrapings

  • A number of experts advise that the diagnosis of pityriasis versicolor can be confirmed on the basis of the clinical findings and fungal microscopy [Gupta, 2004; Gupta, 2015; Hald, 2015] while some advise that this is of no diagnostic value as Malassezia species are part of the normal skin flora [Hay, 2024]. This view is also supported by experts who advise that diagnosis is usually based on clinical features [Renati, 2015; Leung, 2022].  
  • The recommendations on when to consider taking skin scrapings for microscopy are pragmatic based on what CKS considers good medical practice.

What else might it be?

  • The differential diagnoses of pityriasis versicolor are broad. Other conditions that may present with similar clinical features include:
    • Vitiligo — especially in people with hypopigmented lesions. For more information, see the CKS topic on Vitiligo.
    • Psoriasis — particularly guttate psoriasis. For more information, see the CKS topic on Psoriasis.
    • Tinea corporis — a dermatophyte infection of the skin, usually presenting with red or pink patches that enlarge to become ring-shaped lesions with red, scaly borders. For more information, see the CKS topic on Fungal skin infection - body and groin.
    • Seborrhoeic dermatitis — a scaly dermatitis common on the sebum-rich areas of the scalp, face, and trunk that is also linked to Malassezia yeast infection and may coexist with pityriasis versicolor. For more information, see the CKS topic on Seborrhoeic dermatitis.
    • Lyme disease — early Lyme disease often presents with a characteristic 'erythema migrans' rash at the site of the original tick bite. For more information, see the CKS topic on Lyme disease.
    • Pityriasis rosea — a self-limiting skin rash mainly affecting young adults, which is characterized by distinctive, scaly, erythematous lesions. It typically starts with a 'herald' patch followed by a more generalized rash. For more information, see the CKS topic on Pityriasis rosea.
    • Pityriasis alba — ill-defined, slightly scaly, pink patches, which mostly occur on the faces of children and young adults. Patches gradually subside to leave areas of hypopigmentation, which slowly return to normal without treatment, with most resolving over a period of a few months to 1 year.
    • Erythrasma — a skin disease caused by the Gram-positive bacterium Corynebacterium minutissimum. Well-defined pink or brown patches occur, with fine scaling and superficial fissures. Lesions fluoresce coral red under a Wood's lamp. Common sites are axillae, groin and toe web spaces. 
    • Secondary syphilis — may present with a non-itchy, maculopapular rash that may be generalised or only involve the palms of the hands and soles of the feet. See the CKS topic on Syphilis for more information.
    • Melasma (also called chloasma) — brown or greyish patches of pigmentation that most often develop on the face. 

Basis for recommendation

This information is based on expert opinion in a dermatology textbook [Hay, 2024], and narrative reviews Pityriasis versicolor [Gupta, 2002], Tinea versicolor: an updated review [Leung, 2022], and Superficial fungal infections [Schwartz, 2004], the DermNet topics on Erythrasma [DermNet, 2016] and Pityriasis alba [DermNet, 2020], and the British Association of Dermatologists (BAD) patient information leaflet Melasma [BAD, 2024].

Management

Scenario: Management

From age 10 years onwards.

How should I manage people with pityriasis versicolor?

  • Advise the person that:
    • Pityriasis versicolor is not contagious as the yeast that causes it is normally present on human skin — infection is not due to poor hygiene. 
    • Treatment is usually highly effective, but may need to be repeated, as recurrence is common (especially in the summer months). 
    • Following successful treatment, skin discolouration may take several weeks or months to resolve fully. 
    • Further information and support are available in the British Association of Dermatology patient information leaflet Pityriasis versicolor.
  • If an extensive area is involved, prescribe an antifungal shampoo such as:
    • Ketoconazole 2% shampoo:
      • For children aged 12–17 years and adults apply once daily for up to 5 days — the preparation should be used as a body wash and left on the skin for up to 15 minutes then rinsed off.
        • Note: ketoconazole 2% shampoo is not licensed for use in children aged under 12 years.  
  • If only small areas are involved, consider prescribing an antifungal cream as an alternative.
    • Clotrimazole (preferred in pregnancy), econazole, ketoconazole, or terbinafine — apply twice daily for up to 2–3 weeks.
  • If initial topical treatment fails, or if pityriasis versicolor is widespread, see the section on treatment failure.

Basis for recommendation

These recommendations are based on Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases [Hald, 2015], expert opinion in a dermatology textbook [Hay, 2024], and narrative reviews Antifungal treatment for pityriasis versicolor [Gupta, 2015], Tinea versicolor: an updated review [Leung, 2022], and Superficial fungal infections [Schwartz, 2004], the British Association of Dermatologists (BAD) leaflet Pityriasis versicolor [BAD, 2023], and the British National Formulary (BNF) [BNF, 2025]. 

How can I prevent recurrence of pityriasis versicolor?

  • Relapse is common and in most cases, re-treatment of each episode as for the initial presentation is appropriate. 
    • If necessary, consider advising the person to apply ketoconazole shampoo once every 1–4 weeks to the whole body to reduce the risk of recurrence.
    • Ensure the person is aware that re-pigmentation can take several months following successful treatment.
  • If episodes of pityriasis versicolor recur on exposure to warm, humid environments or sunshine, prophylactic treatment prior to exposure (for example, before travel abroad) can be considered.
    • For children aged 12 years and over and adults, apply ketoconazole 2% shampoo once daily for a maximum of 3 days prior to sun exposure. 

Basis for recommendation

These recommendations are based on Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases [Hald, 2015], expert opinion in a dermatology textbook [Hay, 2024], and narrative reviews Antifungal treatment for pityriasis versicolor [Gupta, 2015], Tinea versicolor: an updated review [Leung, 2022], Pityriasis versicolor [Renati, 2015], and the manufacturer's summary of product characteristics for Ketoconazole 2% shampoo [EMC, 2023]. 

  • Experts agree that maintenance or prophylactic treatment may be useful in preventing recurrent infection, however there is limited evidence on efficacy to support recommendations [Leung, 2022; Gupta, 2015; Hald, 2015]. 
    • Expert opinion in a dermatology textbook is that re‐treatment of each episode is preferable to long‐term suppressive therapy [Hay, 2024], while another expert advises that topical application of ketoconazole once a month may reduce relapse [Leung, 2022], and others recommend more frequent application of up to four times monthly [Renati, 2015] for prophylaxis.
    • The use of ketoconazole 2% shampoo as a prophylactic treatment prior to sun exposure is a licensed indication [EMC, 2023]. 

How should I manage treatment failure?

  • If initial topical treatment fails, confirm that the treatment regimen has been followed adequately. 
    • Changes in skin pigmentation usually fully resolve within several weeks of starting antifungal treatment (but may persist for longer). Persisting pigmentary changes in the absence of other signs or symptoms (lesions, erythema, or pruritus) or positive mycology are not necessarily an indication for further treatment.
  • Consider if referral to a dermatologist is required (especially in children aged under 12 years, and pregnant or breastfeeding women). 
  • Consider offering an alternative topical antifungal treatment. 
  • If topical treatment is ineffective, consider offering an oral antifungal drug, such as itraconazole or fluconazole:
    • For adults (not pregnant), prescribe itraconazole 200 mg once daily for 7 days; or fluconazole 50 mg once daily for 2–4 weeks (or 300 mg to 400 mg once weekly for 1-3 weeks). 
    • For pregnant or breastfeeding women and children, seek specialist advice.
  • Consider taking skin scrapings for microscopy to confirm the diagnosis of pityriasis versicolor, if: 
    • The diagnosis is uncertain.
    • The skin lesions do not respond to topical antifungal treatment.
    • Oral antifungal treatment is being considered.

Taking skin samples

  • To take skin scrapings for microscopy:
    • Wipe off any creams before sampling. 
    • Carefully scrape skin from the patches, using a blunt scalpel blade or similar implement (such as a skin scraper). A larger number of microorganisms are most likely to be found in the advancing edge of the patch.
    • Collect as many skin scales as possible (ideally 5 mm2). 
    • Collect the sample into folded dark paper squares (secure with a paper clip), or use a commercially available fungal pack (such as Mycotrans® or Dermapack®).  
  • If very little scale is present and insufficient material can be collected by scraping, skin strippings can be taken: 
    • Apply transparent waterproof adhesive tape to the infected area, peel off and stick to a sterile microscope slide for examination. 
  • Send the sample to the laboratory for microscopy, ensuring that clinical details are stated, including any treatment received and overseas travel history. 

Basis for recommendation

These recommendations are based on Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases [Hald, 2015], expert opinion in a dermatology textbook [Hay, 2024], and narrative reviews Antifungal treatment for pityriasis versicolor [Gupta, 2015], Tinea versicolor: an updated review [Leung, 2022], and Superficial fungal infections [Schwartz, 2004], the British National Formulary (BNF) [BNF, 2025], and what CKS considers good medical practice. 

Second-line topical antifungal treatment
  • The recommendation to try a second-line antifungal treatment before considering oral antifungal treatment is based on the expert opinion of previous external reviewers of this CKS topic.
Skin scrapings for microscopy
  • The information on taking skin scrapings is based on Public Health England guidance [UKHSA, 2016], and what CKS considers good medical practice.
  • The Danish guideline recommends that microscopic examination should be performed to confirm the diagnosis prior to initiation of systemic antifungal therapy [Hald, 2015].

When should I refer a person with pityriasis versicolor?

  • Consider referral to a dermatologist if:
    • The diagnosis is uncertain or skin scraping microscopy is negative.
    • There is an inadequate response to optimal treatment in primary care.
    • The person is a child or pregnant woman, where management options are limited in primary care.
    • Pityriasis versicolor is severe or very extensive.
    • The person is immunocompromized, depending on clinical judgement.
    • Long-term oral antifungal prophylaxis may be needed for recurrent or severe episodes of pityriasis versicolor.

Basis for recommendation

These recommendations are based on Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases [Hald, 2015], expert opinion in a narrative review Antifungal treatment for pityriasis versicolor [Gupta, 2015], and what CKS considers to be good medical practice.

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Ketoconazole 2% shampoo

Ketoconazole 2% shampoo

  • Possible adverse effects include:
    • Dry skin, folliculitis, hair changes, contact dermatitis, erythema, skin and eye irritation, and skin burning sensation.

[EMC, 2023; BNF, 2025]

Topical antifungals

Antifungal creams

  • Contraindications and cautions 
    • Pregnancy
      • Econazole — manufacturers recommend avoidance in pregnancy.
      • Miconazole — manufacturers advise caution.
      • Terbinafine — should not be used during pregnancy unless clearly necessary.
    • Breastfeeding 
      • Econazole — if used while breastfeeding, care should be taken to ensure the cream is not applied to the nipple or surrounding area.
      • Miconazole — manufacturer advises caution in breastfeeding. 
      • Terbinafine — manufacturer advises that it should not be used in women who are breastfeeding, and infants must not be allowed to come into contact with any treated skin, including the breast.
  • Drug interactions
    • Miconazole or econazole 
      • Rarely the effects of oral anticoagulants (such as warfarin) may be enhanced — monitor the person’s international normalised ratio (INR) more closely if used concurrently and adjusted the anticoagulant dose accordingly.
  • Adverse effects
    • Local irritation and hypersensitivity reactions include mild burning sensation, erythema, skin hypopigmentation, and itching. 

[EMC, 2022a; EMC, 2024a; EMC, 2024b; EMC, 2024c; BNF, 2025]

Oral fluconazole

Contraindications and cautions

Do not prescribe oral fluconazole to people:

  • With acute porphyria.
  • Taking other drugs known to cause QT interval prolongation and which are metabolised by cytochrome CYP3A4 (such as cisapride, astemizole, pimozide, quinidine, and erythromycin). 

Prescribe oral fluconazole with caution to people:

  • Susceptible to QT interval prolongation.
  • With hepatic impairment — discontinue if signs or symptoms of hepatic disease develop (asthenia, anorexia, persistent nausea, vomiting and jaundice).  
  • With renal impairment — in people with creatinine clearance less than 50 mL/min, use the usual initial dose then halve any subsequent doses.

[EMC, 2024d; BNF, 2025]

What are the adverse effects of oral fluconazole?

  • Cardiac — torsades de pointes (rarely).
  • Gastrointestinal — abdominal discomfort, vomiting, diarrhoea, nausea (common); constipation, dyspepsia, flatulence, dry mouth (uncommon).
  • Hepatobiliary — liver enzyme increases (common); cholestasis, jaundice (uncommon).
    • Rarely: hepatic failure, hepatic necrosis.
  • Nervous system — headache (common); seizures, paraesthesia, taste disturbance, dizziness (uncommon).
    • Rarely: tremor.
  • Skin and subcutaneous tissue – rash (common); drug eruption, urticaria, pruritus, increased sweating (uncommon).
    • Rarely: toxic epidermal necrolysis, Stevens-Johnson syndrome, exanthematous-pustulosis, dermatitis exfoliative, angioedema, face oedema, alopecia.
    • Frequency unknown: drug reaction with eosinophilia and systemic symptoms (DRESS).
  • Other adverse effects include:
    • Blood dyscrasias.
    • Decreased appetite, hypercholesterolaemia.
    • Fatigue, malaise, fever.
    • Insomnia.
    • Myalgia.
    • Vertigo.

[EMC, 2024d; BNF, 2025]

What are the drug interactions of oral fluconazole?

  • Clopidogrel — levels likely to be modestly reduced by fluconazole. Avoid concurrent use.
  • Drugs that prolong the QT interval (such as amiodarone, amisulpride, fluconazole, sildenafil, mizolastine, hydroxyzine)  — concurrent use is contraindicated. 
  • Mifepristone — fluconazole levels may be increased. If concurrent use is necessary, monitor closely and if required use the lowest possible dose of fluconazole.
  • Fluconazole may increase levels of the following drugs:
    • Alfentanil, fentanyl — monitor for prolonged sedation and respiratory depression.
    • Buspirone — start with a low dose of buspirone, or reduce the buspirone for people already taking it.
    • Calcium channel blockers (amlodipine, verapamil) — monitor for adverse effects if taken concomitantly, and fluconazole dose is over 200 mg daily.
    • Carbamazepine, phenytoin — monitor levels and adjust dose if necessary.
    • Ciclosporin, tacrolimus, and sirolimus — monitor concentrations when fluconazole is started or stopped.
    • Cilostazol — monitor for adverse effects.
    • Cisapride — concurrent use is contraindicated, increased risk of Torsades de pointes.
    • Colchicine — dose adjustment may be necessary.
    • Eletriptan — there may be an increased risk of adverse effects.
    • Eplerenone — the manufacturer advises a maximum eplerenone dose of 25 mg daily.
    • Ergot alkaloids (such as ergotamine and ergometrine) — increased risk of ergotism. Be alert for adverse effects if used concomitantly.
    • Ivabradine — if given concomitantly, reduce initial dose to 2.5 mg twice daily and monitor heart rate.
    • Lomitapide — concurrent use is contraindicated. 
    • Midazolam — dose reductions up to 50% may be required.
    • Methadone — monitor for adverse effects and adjust dose of methadone if required.
    • Mizolastine — monitor for adverse effects.
    • Phospodiesterase-5 inhibitors (avanafil, sildenafil, vardenafil) — reduce doses.
    • Quetiapine — concurrent use with fluconazole is contraindicated. If necessary, monitor for adverse effects and adjust dose.
    • Rifabutin — increased risk of uveitis. Reduce rifabutin dose to 300 mg daily.
    • Statins (lovastatin, simvastatin) — may increase risk of rhabdomyolysis. Advise people to report any unexplained muscle weakness or pain.
    • Warfarin — monitor for adverse effects and adjust doses if required.

[Preston, 2025]

Pregnancy and breastfeeding

Pregnancy

  • The manufacturer advises that standard doses and short-term treatments should not be used in pregnancy unless clearly necessary, and high dose and/or prolonged regimens should not be used except for potentially life-threatening infections.
  • The manufacturer recommends a washout period of approximately 1 week (corresponding to 5-6 half-lives) after a single-dose or discontinuation of a course of treatment before becoming pregnant.

Breastfeeding

  • Fluconazole is excreted in breastmilk, but in amounts considered to be too small to be harmful.
  • Breastfeeding can continue after a single oral dose of fluconazole 150 mg. However, the manufacturer advises that for repeated use, or high doses, the benefits of continuing breastfeeding should be considered along with the risk of potential adverse effects on the child.

[EMC, 2024d; BNF, 2025]

Oral itraconazole

What are the contraindications and cautions for oral itraconazole?

  • Do not prescribe itraconazole to people with:
    • Acute porphyria.
    • Ventricular dysfunction or a history of heart failure, unless the infection is life-threatening, or serious.
  • Prescribe itraconazole with caution in people:
    • At high risk of heart failure.
    • With acute liver disease, or a history of hepatotoxicity with other drugs.
    • With renal impairment.
  • Also prescribe itraconazole with caution in:
    • The elderly.
    • Children.

[EMC, 2022b; BNF, 2025]

What are the adverse effects of oral itraconazole?

  • Gastrointestinal — nausea, abdominal pain, vomiting, dyspepsia diarrhoea (common).  
    • Rarely: pancreatitis.
  • Hepatobiliary — hyperbilirubinaemia (uncommon).
    • Rarely: hepatotoxicity (including acute liver failure).
  • Nervous system — headache, dizziness, paraesthesia (uncommon).
    • Rarely: hypoaesthesia.
  • Skin and subcutaneous tissue — rash (common); alopecia, urticaria, pruritus (uncommon).
    • Frequency unknown: toxic epidermal necrolysis, Stevens-Johnson Syndrome, erythema multiforme, exfoliative dermatitis, leukocytoclastic vasculitis, photosensitivity.
  • Other adverse effects include:
    • Arthralgia, myalgia.
    • Congestive heart failure
    • Erectile dysfunction.
    • Hypersensitivity.
    • Leucopenia (rare).
    • Menstrual disorders.
    • Oedema.
    • Pollakiuria, urinary incontinence.
    • Pulmonary oedema.
    • Pyrexia.
    • Tinnitus.
    • Visual disturbance.

[EMC, 2022b; BNF, 2025]

What are the drug interactions of oral itraconazole?

  • Itraconazole levels may be reduced by the following drugs:
    • Carbamazepine, phenobarbital, phenytoin — monitor itraconazole efficacy and increase dose if necessary.
    • Rifampicin, rifabutin — monitor itraconazole efficacy and increase dose if necessary.
    • St John’s wort — avoid concurrent use.
  • Itraconazole levels may be increased by the following drugs:
    • HIV protease inhibitors (ritonavir, indinavir) — monitor for adverse effects.
    • Clarithromycin, and erythromycin — monitor for adverse effects.
  • Itraconazole may increase levels of the following drugs:
    • Abiraterone — monitor for adverse effects and reduce dose if necessary.
    • Alfentanil, fentanyl — monitor for prolonged sedation and respiratory depression.
    • Aliskiren — contraindicated. If concurrent use is unavoidable, monitor for adverse effects.
    • Antineoplastic agents (vinca alkaloids, busulfan, docetaxel, trimetrexate).
    • Aripiprazole, quetiapine, risperidone — dose reductions may be necessary.
      • Quetiapine — concurrent use with itraconazole is contraindicated. If necessary, monitor for adverse effects and adjust dose.
    • Phospodiesterase-5 inhibitors (avanafil, sildenafil, vardenafil).
      • Avanafil — concurrent use contraindicated.
      • Reduce dose of sildenafil, or vardenafil.
    • Benzodiazepines (alprazolam, triazolam, midazolam) — dose reductions may be required.
    • Buspirone — reduce the buspirone dose to 2.5 mg daily or twice daily.
    • Calcium channel blockers
      • Amlodipine, verapamil — monitor for adverse effects.
      • Lercanidipine —concurrent use contraindicated.
    • Ciclosporin, tacrolimus, and sirolimus — monitor concentrations when itraconazole is started or stopped.
    • Cilostazol — monitor for adverse effects.
    • Cisapride — avoid concurrent use, increased risk of torsades de pointes.
    • Colchicine — dose adjustment may be necessary.
    • Corticosteroids (budesonide, dexamethasone) — avoid concurrent use.
    • Daridorexant — avoid concurrent use.
    • Dofetilide — concurrent use is contraindicated.
    • Digoxin — monitor the effects of digoxin, dose may need to be reduced by 50-75%.
    • Disopyramide — avoid concurrent use.
    • Domperidone — possible increased risk of ventricular arrhythmias. Concurrent use contraindicated.
    • Eletriptan — avoid concurrent use.
    • Eplerenone, dronedarone — concurrent use is contraindicated.
    • Ergot alkaloids (such as ergotamine and ergometrine) — increased risk of ergotism. Concurrent use is contraindicated.
    • Ivabradine — concurrent use is contraindicated.
    • Methadone — monitor for adverse effects and adjust dose of methadone if required.
    • Mizolastine — monitor for adverse effects.
    • Oral anticoagulants
      • Warfarin — be aware of unexplained increases in INR and adjust dose accordingly.   
      • Apixaban — avoid concurrent use.
      • Dabigatran — avoid concurrent use.
      • Edoxaban — dose adjustment may be required. Monitor for signs and symptoms of bleeding or anaemia; especially, in elderly patients and in those with renal impairment.
      • Rivaroxaban — concurrent use is not recommended. If concurrent use is unavoidable, monitor closely and adjust dose of rivaroxaban if necessary.  
    • Pimozide — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Quinidine — increased risk of torsades de pointes. Concurrent use is contraindicated, but if necessary, monitor for adverse effects and reduce dose if required.
    • Ranolazine — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Reboxetine — monitor for adverse effects and adjust dose if required.
    • Rimegepant — avoid concurrent use. 
    • Salmeterol — avoid concurrent use.
    • Solifenacin — restrict dose of solifenacin to 5 mg daily.
    • Statins (lovastatin, simvastatin) — concurrent use contraindicated.
    • Ticagrelor — avoid concurrent use. 

[Preston, 2025]

Pregnancy and breastfeeding

Pregnancy

  • Itraconazole is not recommend for use in women who are pregnant.
    • Women of childbearing age taking itraconazole should use contraception until the next menstrual period following the end of treatment.
  • The manufacturer advises that itraconazole may be given if the fungal infection is life-threatening and the potential benefit outweighs the potential risk to the foetus.

Breastfeeding

  • Itraconazole is excreted in small amounts in breastmilk. However, the manufacturer advises that it should be avoided.

[EMC, 2022b; BNF, 2025]

Supporting evidence

This CKS topic is largely based on Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases [Hald, 2015], and expert opinion in a dermatology textbook [Hay, 2024], and narrative reviews Antifungal treatment for pityriasis versicolor [Gupta, 2015], Tinea versicolor: an updated review [Leung, 2022], and Superficial fungal infections [Schwartz, 2004]. The rationale for individual recommendations is discussed in the relevant basis for recommendation sections of this topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of pityriasis versicolor.

Search dates

February 2020 - February 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 17th February 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.

S5    S1 OR S2 OR S3 OR S4 
S4    AB malassezia OR TI malassezia 
S3    (MH "Malassezia") 
S2    AB ( (tinea or pityriasis) N2 versicolor ) OR TI ( (tinea or pityriasis) N2 versicolor ) 
S1    (MH "Tinea Versicolor") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • BAD (2023) Pityriasis versicolor. British Association of Dermatologists. https://www.bad.org.uk [Free Full-text]
  • BAD (2024) Melasma. British Association of Dermatologists. https://www.bad.org.uk [Free Full-text]
  • BNF (2025) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • DermNet (2016) Erythrasma. DermNet. https://dermnetnz.org [Free Full-text]
  • DermNet (2020) Pityriasis alba. DermNet. https://dermnetnz.org [Free Full-text]
  • EMC (2022a) SPC for Clotrimazole Cream 1%. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2022b) SPC for Itraconazole 10mg/ml Sugar Free Oral Solution. Electronic Medicines Compendium. Datapharm Communications Ltd. [Free Full-text]
  • EMC (2023) SPC for Ketoconazole 2% w/w Shampoo. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024a) SPC for Daktarin 2% Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024b) SPC for Pevaryl 1% Topical Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024c) SPC for Lamisil AT 1% Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024d) SPC for Canesten Thrush Oral Capsule 150mg capsule. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Gupta, A., Bluhm, R. and Summerbell, R. (2002) Pityriasis versicolor. Journal of the European Academy of Dermatology and Venereology 16(1), 19-33. [Abstract]
  • Gupta, A. Batra, R., Bluhm, R., Boekhout, T. and Dawson Jr, T.L. (2004) Skin diseases associated with Malassezia species. Journal of the American Academy of Dermatology 51(5), 785-798. [Abstract]
  • Gupta, A. and Foley, K. (2015) Antifungal treatment for pityriasis versicolor. Journal of Fungi 1(1), 13-29. [Abstract]
  • Hald, M., Arendrup, M., Svejgaard, E., et al. (2015) Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. Acta Dermato Venereologica 95(1), 12-19. [Abstract]
  • Hay, R.J. (2024) Pityriasis versicolor. In: Griffiths, C.E.M., Barker, J., Bleiker, T.O., et al. (Eds.) Rook's Textbook of Dermatology. 10th edn. Oxford: Wiley-Blackwell, 32.10-32.13.
  • Kallini, J.R., Riaz, F. and Khachemoune, A. (2014) Tinea versicolor in dark-skinned individuals. International Journal of Dermatology 53(2), 137-141. [Abstract]
  • Leung, A.K., Barankin, B., Lam, J.M., et al. (2022) Tinea versicolor: an updated review. Drugs in Context 11(2022-9-2). [Abstract]
  • Preston, C.L. (2025) Stockley's Drug Interactions. Medicines Complete. Pharmaceutical press. https://www.medicinescomplete.com
  • Renati, S., Cukras, A. and Bigby, M. (2015) Pityriasis versicolor. BMJ 350(h1394). [Abstract]
  • Schwartz,R.A. (2004) Superficial fungal infections. 364(9440), 1173-1182. [Abstract]
  • UKHSA (2016) UK standards for microbiology investigations. Investigation of dermatological specimens for superficial mycoses. UK Health Security Agency. https://www.rcpath.org [Free Full-text]
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