Background: Pityriasis versicolor is a common fungal infection of the superficial skin layer caused by Malassezia furfur, a normal commensal in the skin. Keratolytic agents are popular, cheap, and readily available over-the-counter treatments for pityriasis versicolor. Conventional antifungal agents are more expensive, requiring prescription, and may induce resistant strains. However, evidence of their comparative safety and efficacy is still lacking. Objectives: To assess the efficacy and safety of synthetic antifungals compared to keratolytic agents in the topical treatment of pityriasis versicolor through a systematic review. Methods: We searched the following databases: MEDLINE (from 1966) through PubMed, CENTRAL (Issue 9 of 12, September 2021), EMBASE (from 1974), LILACS (from 1987); Herdin (from 1970), www.clinicaltrials.gov, www. isrctn.com, www.trialregister.nl. We contacted researchers in the field, hand searched relevant conference abstracts, and the Journal of the Philippine Dermatological Society 1992-2019. We included all randomized controlled trials involving patients with diagnosed active pityriasis versicolor where topical antifungal was compared with a topical keratolytic for treatment. Two review authors independently applied eligibility criteria, assessed risk of bias using the Cochrane collaboration tool, and extracted data from included studies. We used RevMan 5.3 to pool dichotomous outcomes using risk ratios (RR) and continuous outcomes using the mean difference (MD), using random-effects meta-analysis. We tested for statistical heterogeneity using both the Chi² test and the I² test. We presented results using forest plots with 95% confidence intervals. We planned to create a funnel plot to determine publication bias but were unable to due to few studies. A Summary of Findings table was created using GRADE profile software for the primary outcomes. Results: We included 8 RCTs with a total of 617 participants that compared azole preparations (ketoconazole, bifonazole and econazole) versus keratolytic agents (selenium sulfide, adapalene, salicylic-benzoic acid). Pooled data showed that azoles did not significantly differ from keratolytic agents for clinical cure (RR 0.99, 0.88, 1.12; 4 RCTs, N=274, I2=55%; very low-quality evidence), and adverse events (0.59 [0.17, 2.06]; very low-quality evidence) based on 6 RCTs (N=536). There were two patients given a keratolytic agent (selenium sulfide shampoo) who had acute dermatitis and discontinued treatment. Conclusion It is uncertain whether topical azoles are as effective as keratolytic agents in clinical clearance and occurrence of adverse events in patients with pityriasis versicolor. A wider search of grey literature and local studies are warranted. Larger RCTs with low risk of bias are recommended.
Azoles ; Tinea Versicolor

Evodiamine, a bioactive indole alkaloid from Evodia rutaecarpa, E. rutaecarpa var. officinalis, or E. rutaecarpa var. bodinieri, has been extensively investigated due to its pharmacological activities in recent years. At present, evodiamine is proved to significantly suppress the proliferation of a variety of cancer cells and mediate cell processes such as cell cycle arrest and cell migration. In addition, evodiamine displays significant pharmacological activities against cardiovascular diseases(hyperlipidemia, etc.), and tinea manus and pedis. Recently, evodiamine has been found to have potential toxic effects, such as hepatotoxicity, nephrotoxicity, and cardiotoxicity. However, the pharmacological and toxicological mechanism of evodiamine is not clear, and its toxicity in vitro and in vivo has been rarely reported. Therefore, this study reviewed the pharmacological and toxicological articles of evodiamine in recent years, aiming at providing new ideas and references for future research.
Evodia ; Hand Dermatoses ; Humans ; Plant Extracts ; Quinazolines/toxicity* ; Tinea

Background: Carica papaya latex has been found to have antifungal properties rendering an alternative treatment for fungal infections, i.e. pityriasis versicolor. It has remarkable mycelial inhibition, and static effect on fungal growth in cultures. Its keratolytic effect can remove diseased skin cells, and enhance drug penetration. Moreover, it is organic, locally available, and relatively inexpensive. Objective: To compare the efficacy and safety of 1.5% Carica papaya latex cream vs. 2% ketoconazole cream in the treatment of pityriasis versicolor among Filipinos. Methods: A single-center, parallel group, triple-blind, randomized controlled trial in the Dermatology out-patient clinic of Makati Medical Center was conducted. Sixty-four patients with pityriasis versicolor were randomly allocated to the two treatment groups, and received either 1.5% Carica papaya latex cream or 2% ketoconazole cream that they used twice daily for four weeks or until cured. The participants, researcher, and assessor were blinded to the treatment assignments. Therapeutic response was assessed at weeks 1, 2, 3 and 4 based on clinical and mycologic cure. Adverse events were identified. Patients’ assessment of their improvement was done at the end of the treatment. Results: All 64 subjects in both treatment groups (100% in the Carica papaya and 100% in the ketoconazole group) achieved clinical and mycologic cure within the four-week study period. The adverse reactions noted (pruritus and erythema for Carica papaya latex cream, and pruritus for ketoconazole cream) were mild, did not cause disruption of daily activities, and spontaneously resolved. Conclusion 1.5% Carica papaya latex cream is an effective and safe alternative treatment to the first line therapy, ketoconazole cream, for pityriasis versicolor.
Carica ; Tinea Versicolor

Objective: To determine the efficacy of Guava 5% cream compared to Clotrimazole 1% cream in the treatment of Tinea corporis of patients seen at Family Medicine Department of Quezon City General Hospital Design: Randomized therapeutic clinical trial Setting: Department of Family and Community Medicine Out Patient Department of Quezon City General Hospital Study Subjects: Patients, male or female, 19 years old and above who consulted at Family and Community Medicine Department of Quezon City General Hospital Method: The study was done from August- September 2019. Fifty subjects were randomly assigned to either Group A (25) or Group B (25) using systematic sampling method. Patients in Group A were instructed to apply on affected area Clotrimazole 1% Cream twice a day for 2 weeks, while patients on Group B applied Guava 5% cream twice a day for 2 weeks. Patients were instructed follow up on Week 1 for improvement, Week 2 for evaluating outcome of treatment and Week 4 to check for recurrences Results: Total severity scores of both Groups A and B at Week 1, Week 2 and Week 4 were similar with p-values of 0.014, 0.480 and 0.386 respectively. Both groups were comparable as to the treatment outcome for Tinea corporis. Guava 5% cream is shown to be cost-effective considering the equally-effective treatment outcome and the lower average treatment cost Conclusion This study has shown that Guava 5% cream is equally effective as, and cheaper than Clotrimazole 1% cream, thus considered to be a cost-effective treatment for Tinea corporis.
Tinea ; Psidium ; Clotrimazole

Skin mycoses have been a major problem affecting millions around the globe. The threat of resistance to synthetic antifungal agents however is a major obstacle in its management. As an alternative to these, a thorough investigation of natural products is being performed to develop medicines that are effective and safe. In this review, we described three antifungal herbal plants that are available in the Philippines, namely Senna alata (Linn.) Roxb. (akapulko), Allium sativum (Linn.) (garlic) and Cymbopogon citratus (DC.) Stapf (lemongrass). In vitro studies showed promising results that can be used as a basis for drug formulation for community use as well as commercial products. So far, there have been no reported toxic effects from these plants. The common ground for these plants’ mechanism of action was the effect of their phytochemicals in the cell membrane and cell wall organelles, inhibition of major biosynthetic pathways, and prevention of biofilm formation. Formulation and clinical studies also revealed promising results comparable to the synthetic ones.
Tinea ; Garlic

OBJECTIVE: The study aimed to assess the efficacy and safety of Senna alata (akapulko) plant extracts compared with topical antifungals in the treatment of superficial fungal skin infections.

METHODS: A systematic review and meta-analysis of randomized controlled trials that studied patients with diagnosed cutaneous tinea or dermatophytosis (excluding hair and nail), tinea versicolor, or cutaneous candidiasis, via microscopy or culture, and compared the efficacy and safety of S. alata (akapulko) extract versus topical antifungals. Two authors independently screened titles and abstracts of merged search results from electronic databases (The Cochrane Skin Group Specialized Register, CENTRAL, MEDLINE, EMBASE (January 1990 to December 2011), Health Research and Development Information Network (HERDIN), and reference lists of articles), assessed eligibility, assessed the risk of bias using the domains in the Cochrane Risk Bias tool and collected data using a pretested Data extraction form (DEF). Meta-analyses were performed when feasible.

RESULTS: We included seven RCTs in the review. There is low certainty of evidence that S. alata 50% lotion is as efficacious as sodium thiosulfate 25% lotion (RR 0.91, 95% CI, 0.79 to 1.04; 4 RCTs, n=216; p=0.15; I2=52%) and high quality evidence that S. alata cream is as efficacious as ketoconazole (RR 0.95, 95% CI, 0.82 to 1.09; 1 RCT, n=40; p=0.44) and terbinafine cream (RR 0.93, 95% CI, 0.86 to 1.01; 1 RCT, n=150; p=0.09) in mycologic cure. For adverse effects, there is very low certainty of evidence of increased harm with S. alata 50% lotion compared to sodium thiosulfate 25% lotion (RR 1.26, 95% CI, 0.46, 3.44; 2 RCTs, n=120; p=0.65; I2=19%). Adverse effects were few and mild.

CONCLUSION: S. Alata 50% lotion may be as efficacious as sodium thiosulfate 25% lotion and is as efficacious as ketoconazole 2% and terbinafine 1% creams. There is insufficient evidence to compare the safety of S. alata 50% lotion with sodium thiosulfate 25% lotion.

Background: Pityriasis versicolor is a common fungal infection of the superficial skin layer caused by Malassezia furfur, a normal commensal in the skin. Keratolytic agents are popular, cheap, and readily available over-the-counter treatments for pityriasis versicolor. Conventional antifungal agents are more expensive, requiring prescription, and may induce resistant strains. However, evidence of their comparative safety and efficacy is still lacking. Objectives: To assess the efficacy and safety of synthetic antifungals compared to keratolytic agents in the topical treatment of pityriasis versicolor through a systematic review. Methods: We searched the following databases: MEDLINE (from 1966) through PubMed, CENTRAL (Issue 9 of 12, September 2021), EMBASE (from 1974), LILACS (from 1987); Herdin (from 1970), www.clinicaltrials.gov, www. isrctn.com, www.trialregister.nl. We contacted researchers in the field, hand searched relevant conference abstracts, and the Journal of the Philippine Dermatological Society 1992-2019. We included all randomized controlled trials involving patients with diagnosed active pityriasis versicolor where topical antifungal was compared with a topical keratolytic for treatment. Two review authors independently applied eligibility criteria, assessed risk of bias using the Cochrane collaboration tool, and extracted data from included studies. We used RevMan 5.3 to pool dichotomous outcomes using risk ratios (RR) and continuous outcomes using the mean difference (MD), using random-effects meta-analysis. We tested for statistical heterogeneity using both the Chi² test and the I² test. We presented results using forest plots with 95% confidence intervals. We planned to create a funnel plot to determine publication bias but were unable to due to few studies. A Summary of Findings table was created using GRADE profile software for the primary outcomes. Results: We included 8 RCTs with a total of 617 participants that compared azole preparations (ketoconazole, bifonazole and econazole) versus keratolytic agents (selenium sulfide, adapalene, salicylic-benzoic acid). Pooled data showed that azoles did not significantly differ from keratolytic agents for clinical cure (RR 0.99, 0.88, 1.12; 4 RCTs, N=274, I2=55%; very low-quality evidence), and adverse events (0.59 [0.17, 2.06]; very low-quality evidence) based on 6 RCTs (N=536). There were two patients given a keratolytic agent (selenium sulfide shampoo) who had acute dermatitis and discontinued treatment. Conclusion It is uncertain whether topical azoles are as effective as keratolytic agents in clinical clearance and occurrence of adverse events in patients with pityriasis versicolor. A wider search of grey literature and local studies are warranted. Larger RCTs with low risk of bias are recommended.
Azoles ; Tinea Versicolor

BACKGROUND: Tinea capitis manifests either as a non-inflammatory or inflammatory type including kerion, which may cause permanent alopecia. In addition to antifungals, systemic corticosteroids (prednisolone at 1~2 mg/kg/day) have been used to reduce inflammation in patients with kerion. OBJECTIVE: We studied the clinical and laboratory features, treatments, and prognosis of tinea capitis. METHODS: We performed a retrospective review of 12 cases of kerion and 12 cases of non-inflammatory tinea capitis (median age, 8 years; range, 3 months~80 years) diagnosed using a potassium hydroxide mount at the National Health Insurance Service Ilsan Hospital between November 2011 and April 2018. RESULTS: Fungal cultures showed Microsporum species in 6 cases and Trichophyton species in 1 case. The duration of diseases and extent of lesions were greater in the kerion group than in the non-inflammatory tinea capitis group (p<0.05). Sixteen patients were treated with systemic antifungals. In the kerion group, 10 patients were treated with systemic antifungals (6 with itraconazole [median, 26 days; range, 21~58 days] and 4 with terbinafine [median, 24.5 days; range, 13~31 days]). The median intervals between the onset of treatment and scalp clearing (in 10 cases), the onset of new hair growth (in 9 cases), and complete regrowth of hair (in 7 cases) were 27 (range, 13~77), 33 (range, 19~63), and 89 (range, 42~180) days, respectively, in the kerion group. The median dosage of prednisolone used in patients with kerion was 0.26 mg/kg/day (range, 0.15~0.42) with good clinical response. CONCLUSION: The patients with kerion responded well to antifungal treatments. A lower dose of prednisolone was adequate when systemic corticosteroids were required for the treatment of kerion.
Adrenal Cortex Hormones ; Alopecia ; Hair ; Humans ; Inflammation ; Itraconazole ; Microsporum ; National Health Programs ; Potassium ; Prednisolone ; Prognosis ; Retrospective Studies ; Scalp ; Tinea Capitis ; Tinea ; Trichophyton

BACKGROUND: In Korea, new human immunodeficiency virus (HIV) patients continue to be diagnosed. Due to the development of highly active anti-retroviral therapy (HAART) and lengthening of survival period of infected person, the aspect of skin diseases of HIV-infected patients is also changing. OBJECTIVE: To determine skin diseases of HIV-infected patients according to immune status and the relationship between folliculitis and HAART drug. METHODS: Subjects were HIV-infected patients who were treated in the department of dermatology from September 1, 2008 to August 31, 2018. Medical records of 376 subjects were retrospectively analyzed. RESULTS: Of 376 patients were studied, tinea infection, folliculitis, and seborrheic dermatitis were the most common regardless of their CD4 T cell counts or treatment group (initial treatment or retreatment). Seborrheic dermatitis, irritant contact dermatitis, and pruritic papular eruption were significantly more common in patients with CD4+T cells less than 200×106 cells/L while warts were significantly more frequent in patients with CD4+T cells greater than 200×106 cells/L. Most HAART agents were found to be helpful in reducing the incidence of folliculitis. CONCLUSION: There were many skin diseases in HIV patients, different from previous studies. In our study, the top three diagnoses were tinea infection, folliculitis, and seborrheic dermatitis. HAART medication was helpful in reducing folliculitis. These changes will require different treatments for skin diseases in HIV patients.
Acquired Immunodeficiency Syndrome ; Antiretroviral Therapy, Highly Active ; Cell Count ; Dermatitis, Contact ; Dermatitis, Seborrheic ; Dermatology ; Diagnosis ; Folliculitis ; HIV ; Humans ; Incidence ; Korea ; Medical Records ; Retrospective Studies ; Skin Diseases ; Skin ; Tinea ; Warts

Background: Oral azole drugs are a second-line option for the treatment of pityriasis versicolor but evidence on their efficacy and safety is unclear. Objectives. To determine the efficacy and safety of oral azoles in the treatment of patients with pityriasis Versicolor.

Methods: We searched MEDLINE, CENTRAL, EMBASE, LILACS, and HERDIN, from inception to the period between January to February 2014. We did not restrict the search by language or publication status. We included randomized controlled trials (RCTs) that compared the efficacy of oral azoles with placebo or no treatment, with topical agents, other oral azoles or dosing regimens in the treatment of pityriasis Versicolor, and that measured any of the pre-specified outcomes (mycologic cure, clinical cure, recurrence, duration to cure, time-to-cure, and quality of life). For adverse effects, we also included non-randomized studies (NRS). We used Cochrane methods to select studies, extract data, assess the risk of bias, pool studies, and calculate for treatment effects.

Results: We included 38 RCTs (n=2894) and 56 NRS (n=3452). Overall, there were few pooled studies and evidence was low to moderate quality. Oral azoles were more effective than placebo (mycologic cure, RR 11.34, 95% CI 4.90, 26.28; 3 RCTs, n=131; I2=0%; low quality of evidence) and as effective as topical agents (mycologic cure, RR 1.02, 95% CI 0.86, 1.21; 4 RCTs, n=232; I2=60%; moderate quality of evidence).There were few adverse effects and were mostly minor and transient.

Conclusions: Oral azoles may be more effective than placebo, and are probably as effective as topical agents in the treatment of PV. Triazoles are probably as effective as ketoconazole. Adverse effects were few, mostly minor, and transient.