Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

nonpregnant

1st line – topical therapy

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ACUTE
|
nonpregnant
1st line – 

topical therapy

Preferred first-line therapy for all patients, especially children.[37]

Most topical therapies are generally equally effective, and selection is based on patient preference. Advise patients to treat the whole neck, trunk, arms, and legs down to the knees, even if only small areas are involved.[25]

Nonspecific topical therapies are older and relatively inexpensive. These agents include pyrithione zinc, propylene glycol, and selenium sulfide.[1][14] Selenium sulfide may cause a stinging sensation after application and some patients complain about its odor.[25] In the US, pyrithione zinc is available OTC in several preparations, but propylene glycol has to be prepared by a compounding pharmacy.

Newer topical therapies include terbinafine, ciclopirox, and azole antifungals such as ketoconazole, clotrimazole, and miconazole.

Topical retinoids (e.g., tretinoin, adapalene) may also be used.[40][39]

There is no benefit of one over another, other than appropriate selection of a base (i.e., for hair-bearing skin, lotions, shampoos, and solutions are better than cream-based products).

Primary options

pyrithione zinc topical: (1%) children >2 years of age and adults: apply to whole neck, trunk, arms, and legs once daily for 2 weeks

OR

propylene glycol topical: (50%) children and adults: apply to whole neck, trunk, arms, and legs twice daily for 2 weeks

OR

selenium sulfide topical: (2.5%) children and adults: apply to whole neck, trunk, arms, and legs once daily for 1 week

OR

ciclopirox topical: (0.77%) children >10 years of age and adults: apply to whole neck, trunk, arms, and legs once daily for 4 weeks

OR

ketoconazole topical: (2%) children and adults: apply to whole neck, trunk, arms, and legs once or twice daily for 2 weeks

OR

clotrimazole topical: (1%) children and adults: apply to whole neck, trunk, arms, and legs twice daily for 2 weeks

OR

miconazole topical: (2%) children and adults: apply to whole neck, trunk, arms, and legs twice daily for 2 weeks

OR

terbinafine topical: (1%) children and adults: apply to whole neck, trunk, arms, and legs twice daily for 2 weeks

OR

tretinoin topical: children ≥12 years of age and adults (0.1%) apply to whole neck, trunk, arms, and legs once daily for 2 weeks

OR

adapalene topical: children ≥12 years of age and adults (0.1%) apply to whole neck, trunk, arms, and legs once daily for 2 weeks

Consider – UV light

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ACUTE
|
nonpregnant
Consider – 

UV light

Treatment recommended for SOME patients in selected patient group

Especially in patients with hypopigmented PV, the resulting dyschromia can be long lasting, even after successful pathogen eradication. In patients with prominent hypopigmented PV, consider UV phototherapy after complete eradication of the fungus, as demonstrated by a potassium hydroxide (KOH) preparation. Repigmentation can be expected within 3 weeks after starting UV therapy such as UV-B 3 times weekly.[52]

UV-B is safe in children old enough to tolerate standing in the booth.

2nd line – systemic antifungal

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ACUTE
|
nonpregnant
2nd line – 

systemic antifungal

Primarily indicated for lesions that are extensive and resistant to topical therapy, and for patients who are immunosuppresed, experience frequent relapses, and have difficulty complying with topical therapies as they are more convenient and less time consuming to use.[14]

Used only for short time periods to minimize the risk of adverse effects.[25]

Systemic agents include fluconazole, itraconazole, or ketoconazole.[7][13][14][20][43][44] Systemic azole antifungals differ little in efficacy.[7] However, the safety and efficacy of oral itraconazole has not been established in children. While studies have failed to consistently demonstrate the efficacy of a single dose of itraconazole in the treatment of PV, there is some evidence to suggest that a short course of itraconazole may be as effective as a multi-day course of treatment.[43][45][46] Ketoconazole may cause severe liver injury and adrenal insufficiency. In July 2013, the US Food and Drug Administration (FDA) recommended that oral ketoconazole should only be used for life-threatening fungal infections where alternative treatments are not available or tolerated, and when the potential benefits of treatment outweigh the risks. Its use is contraindicated in patients with liver disease. If used, monitor liver and adrenal function before and during treatment.[47]

Resistance to traditional systemic agents such as itraconazole and fluconazole has been described, which may necessitate higher doses and longer courses of these medications, or primary use of older topical treatments such as selenium sulfide and pyrithione zinc.[48]

Oral terbinafine and griseofulvin are ineffective in treating PV.[7]

As systemic azole antifungals are best absorbed in an acid environment, they should be taken with a carbonated beverage. To increase delivery of the medication to its site of action in the stratum corneum, patients can take it 45 minutes prior to working out to a sweat, and then waiting several hours before having a shower.

Primary options

fluconazole: children: 3-6 mg/kg orally once weekly for 2 weeks; adults: 400 mg orally as a single dose, or 200 mg once weekly for 2 weeks

OR

itraconazole: adults: 400 mg orally once daily for 3 days, or 200 mg orally once daily for 7 days

Secondary options

ketoconazole: children >2 years of age: consult specialist for guidance on dose; adults: 400 mg orally once weekly for 2 weeks

Consider – UV light

Back
ACUTE
|
nonpregnant
Consider – 

UV light

Treatment recommended for SOME patients in selected patient group

Especially in patients with hypopigmented PV, the resulting dyschromia can be long lasting, even after successful pathogen eradication. In patients with prominent hypopigmented PV, consider UV phototherapy after complete eradication of the fungus, as demonstrated by a KOH preparation. Repigmentation can be expected within 3 weeks after starting UV therapy such as UV-B 3 times weekly.[52]

UV-B is safe in children old enough to tolerate standing in the booth.

pregnant

1st line – topical therapy

Back
ACUTE
|
pregnant
1st line – 

topical therapy

Most topical therapies are generally equally effective, and selection is based on patient preference. Advise patients to treat the whole neck, trunk, arms, and legs down to the knees, even if only small areas are involved.[25]

Nonspecific topical therapies are older and relatively inexpensive. Pyrithione zinc and propylene glycol have not been adequately tested in pregnant women. However, no teratogenicity or embryotoxicity has been observed in the offspring of laboratory animals treated with pyrithione zinc, and there have been no documented problems in humans.[41][42]

There is inadequate data to support the use of terbinafine or ciclopirox in pregnant women; however, no teratogenicity or embryotoxicity has been observed in animal studies with either drug.

Selenium sulfide and the topical azole antifungals are generally not recommended in pregnancy. However, some clinicians still use selenium sulfide, topically during pregnancy.

Primary options

pyrithione zinc topical: (1%) adults: apply to whole neck, trunk, arms, and legs once daily for 2 weeks

OR

propylene glycol topical: (50%) adults: apply to whole neck, trunk, arms, and legs twice daily for 2 weeks

Secondary options

ciclopirox topical: (0.77%) adults: apply to whole neck, trunk, arms, and legs once daily for 4 weeks

OR

terbinafine topical: (1%) children and adults: apply to whole neck, trunk, arms, and legs twice daily for 2 weeks

Consider – UV light

Back
ACUTE
|
pregnant
Consider – 

UV light

Treatment recommended for SOME patients in selected patient group

Especially in patients with hypopigmented PV, the resulting dyschromia can be long lasting, even after successful pathogen eradication. In patients with prominent hypopigmented PV, consider UV phototherapy after complete eradication of the fungus, as demonstrated by a KOH preparation. Repigmentation can be expected within 3 weeks after starting UV therapy such as UV-B 3 times weekly.[52] UV-B is safe in pregnant women.

ONGOING

recurrent disease after successful pathogen eradication

1st line – prophylactic topical or systemic antifungal

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ONGOING
|
recurrent disease after successful pathogen eradication
|
nonpregnant
1st line – 

prophylactic topical or systemic antifungal

In patients with recurrent disease, prophylactic treatment may be necessary after a successful treatment course.

First-line prophylactic treatment, especially in children, is selenium sulfide.[1]

If topical prophylactic therapy is ineffective, second-line therapies include pulse-dosed oral azole antifungals.[49][50][51] The safety and efficacy of oral itraconazole has not been established in children. Ketoconazole may cause severe liver injury and adrenal insufficiency. In July 2013, the US Food and Drug Administration (FDA) recommended that oral ketoconazole should only be used for life-threatening fungal infections where alternative treatments are not available or tolerated, and when the potential benefits of treatment outweigh the risks. Its use is contraindicated in patients with liver disease. If used, monitor liver and adrenal function before and during treatment.[47]

As systemic azole antifungals are best absorbed in an acid environment, they should be taken with a carbonated beverage.

Primary options

selenium sulfide topical: (2.5%) children and adults: apply to whole neck, trunk, arms, and legs on the first and third day of each month for 6 months

Secondary options

ketoconazole: children >2 years of age: consult specialist for guidance on dose; adults: 400 mg orally once monthly for 6 months, or 200 mg once daily for 3 days at the beginning of each month for 6 months

OR

itraconazole: adults: 400 mg orally once monthly for 6 months

1st line – topical pyrithione zinc

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ONGOING
|
recurrent disease after successful pathogen eradication
|
pregnant
1st line – 

topical pyrithione zinc

In patients with recurrent disease, prophylactic treatment may be necessary after a successful treatment course. First-line prophylactic treatment in pregnant women is pyrithione zinc.

Primary options

pyrithione zinc topical: (1%) adults: apply to whole neck, trunk, arms and legs on the first and third day of each month for 6 months

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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