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Anastasia Pantazidou, Senior House Officer, Department of Paediatrics, North Middlesex Hospital, London, UK; email@example.com
Marc Tebruegge, Specialist Registrar, Department of Paediatric Infectious Diseases, St Mary's Hospital, London, UK
A 14‐year‐old girl is seen in the paediatric outpatient department. She was referred by her general practitioner (GP) with persistent tinea versicolor. The GP had previously treated her with topical clotrimazole over the last few years with varying degree of success. The girl has recently returned from a trip to South America during which she experienced an exacerbation of her symptoms.
On examination you find multiple oval to round shaped lesions which are hypopigmented with superficial scaling, that appear particularly prominent in the axillary region and around the neck. The girl tells you that these areas had previously been darker than the surrounding skin, which was more obvious during the winter months. Under Wood's light examination the lesions appear fluorescent yellow. You obtain samples for microbiological confirmation but concur with the GP that this is tinea versicolor.
The girl expresses her distress about her external appearance and is very keen to finally get rid of this problem. You wonder whether oral antifungal agents may provide a more effective alternative to topical treatment and consult the British National Formulary for Children (BNFC 2006). The formulary states that oral itraconazole should be considered if topical treatment has failed. It also mentions that fluconazole may be used as an alternative. You wonder which of these treatment options is more effective in tinea versicolor.
In a child/adolescent with tinea versicolor [patient] is oral itraconazole more effective than oral fluconazole [intervention] as regards cure [outcome]?
Cochrane Library using the terms “pityriasis versicolor” and “tinea versicolor”: no relevant reviews.
PubMed (1950–to date/no limits set) using the terms “Pityrosporum versicolor”, “Pityrosporum orbiculare”, “Malassezia furfur”, “pityriasis versicolor” and “tinea versicolor” in combination with [AND] itraconazole [AND] fluconazole. Search date 19 November 2006. Results in the same order: 8, 11, 14, 18 and 16 articles. There was considerable overlap between the results produced by the different search terms. Only three articles were relevant which are summarised in table 33.1–3
EMBASE database (1974–to date) using the same set of search terms employed in the PubMed search – results in the same order as above: 0, 4, 34, 28 and 20 articles. This search identified two further relevant publications. One report of an RCT comparing both drugs was published in Turkish only (abstract available in English) and had to be excluded since the details available to us were insufficient, while the second article is summarised in table 33.4
Search of multiple trials registers: UK National Research Register (NRR and MRC), ISRCTN, NIH: no relevant studies identified.
Search date: 9 December 2006.
Tinea versicolor, also called pityriasis versicolor, is a common skin condition which is caused by a superficial cutaneous infection with the fungal agent Malassezia furfur (previously Pityrosporum versicolor or Pityrosporum orbiculare). The infection occurs worldwide, with prevalences from 0.5% in temperate climates up to 18% in humid tropical climates reported in the literature.5 6 Tinea versicolor predominately affects adolescents and adults, but infection as early as in infancy has been described.
The typical clinical finding consists of multiple, oval lesions with fine scaling, which are predominately distributed over the upper areas of the trunk, the upper arms and the neck. Facial involvement is particularly common in children. The lesions may be hypopigmented or hyperpigmented and are frequently associated with pruritus. The areas typically fail to tan during the summer and appear darker than the surrounding unaffected skin in the winter months when they appear yellow to brown in colour. The diagnosis can be confirmed by demonstrating fluorescence under Wood's light (ultraviolet light), microscopic examination of a potassium hydroxide (KOH) preparation or with fungal cultures of skin scrapings.
Although the infection does not pose a significant health risk to the affected individual, the psychological and social implications can be profound. Spontaneous remission is generally rare. Topical treatment as a first line intervention can be curative, for which purpose clotrimazole, econazole, ketoconazole, miconazole or terbinafine can be used. However, some patients do not respond satisfactorily or experience multiple relapses and may require systemic treatment, particularly when large areas are affected. In these circumstances “azole” antifungal drugs, which include fluconazole, itraconazole and ketoconazole, are considered to be the treatment of choice.
None of the studies we identified in our search was conducted in paediatric patients. However, previous studies in children using itraconazole and fluconazole for other purposes have demonstrated that both drugs are generally safe and well tolerated in this age group.7 8 Side effects mainly consist of transient, mild elevation of liver function tests and gastrointestinal symptoms.
There is little consensus regarding the optimal dosing regimen and duration of treatment with systemic antifungal agents. The BNFC suggests a 7‐day course with itraconazole or a 2–4‐week course with fluconazole for the treatment of tinea versicolor. Interestingly, a randomised controlled trial in adults has demonstrated that single high dose (400 mg) fluconazole treatment can be as effective as a prolonged 4‐week course with lower doses with regard to clinical cure.9
All of the studies, with the exception of the report by Silva et al, were rather small and therefore may have been insufficiently powered to demonstrate a significant difference between treatment groups. Regarding clinical cure and improvement, all of the studies included have reported marginally better results with fluconazole, with the exception of the article by Montero‐Gei et al. However, in all four studies the difference between both treatment groups was small and statistically not significant.
The most striking difference between the two treatment options seems to occur in relation to clinical and mycological relapses. Three of the studies assessed the clinical relapse rate.
Although it appears likely that the data from these adult studies can be directly extrapolated to children, a sufficiently powered study comparing fluconazole with itraconazole in paediatric patients suffering from tinea versicolor, with a long follow‐up period that would allow the evaluation of relapse rates, would be desirable. Since there is evidence from adult studies that a single high‐dose antifungal treatment can be as successful as a prolonged course, such a study should ideally re‐evaluate the dosing and duration of treatment for both agents. Ultimately, a shorter treatment course would reduce costs and potentially minimise the risk of adverse events.