An 84 year-old woman presented to me today with classical tinea versicolor (TV) on her neck, chest, and upper back. The KOH was positive for spores and hyphae. Interestingly, she never had it before, having started to appear just a couple of months ago. Once it started to spread, she used 1% hydrocortisone, which helped her minimal pruritus, but the lesions persisted. She was otherwise in excellent health, her medical history being remarkable only for hypercholesterolemia, GERD, and osteoarthritis. I prescribed ketoconazole cream.
While I’m sure she’ll be fine, I cannot help but wonder if I’m missing something. I cannot recall seeing a case of new-onset TV in an otherwise healthy octogenarian.
In an epidemiologic study of 50,237 consecutive Greek dermatology outpatients, with patients aged 35 days to 96 years, the peak prevalence of TV was age 21-25 for men and 26-30 for women. Overall there were 491 cases of TV in 20,909 men (2.3%), but only 7 cases in men older than 70 years (0.3%). Out of 29.328 women, 521 had TV, with only 9 cases in women older than 70 (0.3%) (1). In another study of elderly patients (defined as > 65 year old), TV was reported in 5% (2).
Malassezia furfur proliferates in sebaceous-rich areas, flourishing when there is high heat and humidity. It may certainly be extensive in immunocompromised hosts.
While sebum production stays constant in men, in women, it progressively decreases over a lifetime (3). Presumably, that is the main reason that I cannot recall new onset TV in an octogenarian woman (nor can I remember it in a man, for that matter).
The question remains, do I leave well enough alone, or should I look further and do some basic work-up for immunosuppression and or/endocrine (androgen) status? I’m not sure. I told the patient that I would like to follow-up with her in a couple of months. If she is clear, I’ll likely just put my concerns to rest. If it’s recalcitrant to therapy, I might delve further. What do you think?
- Kyriakis KP, et al. Pityriasis versicolor prevalence by age and gender. Mycoses 2006; 49: 517-8.
- Polat M, Ilhan MN. Dermatological complaints of the elderly attending a dermatology outpatient clinic in Turkey: A prospective study over a one-year period. Acta Dermatovenereol Croat 2015; 23: 277-81.
- Luebberding S, et al. Skin physiology in men and women: In vivo evaluation of 300 people including TEWL, SC hydration, sebum content and skin surface PH. Int J Cosmet Sci 2013; 35: 477-83.