The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

LindseyR. Baden, M.D., Editor

Tinea Versicolor
A B C

A
24-year-old woman presented with a 12-year history of a depig- Alex Holliday, M.D.
menting rash. The rash was most notable in the summer months, with Douglas Grider, M.D.
remission during cooler seasons. She reported prominent scaling of her Carilion Clinic
skin, particularly after showering. Over the preceding 2 to 3 years, the rash had Roanoke, VA
spread to include her entire torso with extension down her arms. She was con- acholliday@gmail.com
cerned that facial involvement might occur. Previous therapies with multiple topical
antifungal agents had not regenerated skin pigmentation. Physical examination
revealed large, coalescing, hypopigmented patches and macules on her torso and
upper arms (Panel A) with scant scaling. A skin biopsy was performed to evaluate
for vitiligo. Melan-A staining confirmed a normal presence of melanocytes (Panel B,
arrows). Subsequent periodic acidSchiff staining revealed the presence of yeast in
a spaghetti and meatball pattern in the superficial epidermis (Panel C, arrow).
A diagnosis of tinea versicolor was made. Scaling that results from stretching or
scraping of the skin is suggestive of tinea versicolor and should prompt examina-
tion under the microscope, when possible, of skin scrapings treated with potas-
sium hydroxide or chlorazol black E. Given the extensive skin involvement, the
patient was treated with a course of oral fluconazole and topical ketoconazole; the
patient was lost to follow-up. The process of skin repigmentation may take months
once the fungal cause is eliminated.
DOI: 10.1056/NEJMicm1501201
Copyright 2016 Massachusetts Medical Society.

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