A 20-year-old student comes to the physician with a rash. She initially noticed it on her chest but then it seemed to spread to her back. The rash itches slightly, but the patient has no other symptoms and feels well. She is not sexually active and has had no genital lesions. General physical examination is within normal limits. The rash is shown in the photograph.

What would be the most appropriate therapy once a definitive diagnosis is established?

Question

A 20-year-old student comes to the physician with a rash. She initially noticed it on her chest but then it seemed to spread to her back. The rash itches slightly, but the patient has no other symptoms and feels well. She is not sexually active and has had no genital lesions. General physical examination is within normal limits. The rash is shown in the photograph.

What would be the most appropriate therapy once a definitive diagnosis is established?

Quizplus · Accepted Answer

This patient most likely has tinea versicolor, a superficial yeast infection frequently caused by Malassezia furfur. Tinea versicolor may present clinically as hypopigmented, hyperpigmented, or erythematous macules and patches. A fine dusty-appearing scale is often present on affected skin. Lesions become more common and obvious during the summer months and favor oily areas such as the chest, back, upper arms, neck, and intertriginous areas. Most patients are asymptomatic, although some may complain of mild pruritus. Diagnosis is made with a potassium hydroxide (KOH) preparation of a skin scraping. The curved hyphae and round yeast cells appear as "spaghetti and meatballs" under the microscope. Topical therapy (eg, ketoconazole, terbinafine, selenium sulfide) is the treatment of choice for patients with limited disease. Patients with widespread disease, recurrent tinea versicolor, or those who have failed topical therapy should receive systemic therapy (eg, oral ketoconazole, itraconazole, fluconazole). (Choice A) Benzathine penicillin is used to treat secondary syphilis, which can present with erythematous to brown macules, papules, or small plaques in a generalized distribution. The palms and soles are frequently involved, and the patient may have a history of chancre. secondary syphilis (Choices B and E) Phototherapy and topical corticosteroids are used for psoriasis and vitiligo. Topical vitamin D analogues (eg, calcipotriene) are also used to treat plaque psoriasis. Psoriasis is characterized by sharply demarcated, erythematous plaques with an overlying thick, silvery scale. Generalized vitiligo (vitiligo vulgaris) often affects the skin surrounding body orifices (eg, mouth, eyes, nose) and sun-exposed surfaces. Vitiligo lesions are completely depigmented. Tinea versicolor affects skin areas with a high number of cutaneous sebaceous glands (upper body), and the lesions are hypopigmented (not depigmented) macules. plaque psoriasis Generalized vitiligo (Choice C) Topical corticosteroids may be used for the treatment of seborrheic dermatitis. However, seborrheic dermatitis on the trunk is usually more erythematous than tinea versicolor and has a thicker scale. Patients typically have other areas of involvement, including the scalp, eyebrows, and nasolabial folds. seborrheic dermatitis Educational objective: Tinea versicolor is a superficial yeast infection that can present as hypopigmented, hyperpigmented, or erythematous macules and patches. Lesions are frequently seen on oily areas of the skin such as the chest, back, upper arms, neck, and intertriginous areas. Diagnosis is established by KOH preparation of a skin scraping. Treatment for limited disease is a topical antifungal agent. Systemic therapy is indicated for patients with widespread disease, recurrent tinea versicolor, or those who have failed topical therapy. __________ References: Pityriasis versicolor. (http://www.ncbi.nlm.nih.gov/pubmed/12956196) Superficial fungal infections. (http://www.ncbi.nlm.nih.gov/pubmed/15451228)

A 20-Year-Old Student Comes to the Physician with a Rash