Although the diagnosis is usually clinically obvious, a KOH taken from a scaly macule will frequently show the classic "spaghetti and meatballs" pattern of pseudohyphae and spores (figure 14).

The goal is to control of the yeast overgrowth on the skin.  It can't be eradicated because it is part of the body's normal flora.  Selenium sulfide suspension (Selsun) applied to the skin, rinsed after 5-10 minutes for 7-14 days initially then reduced to twice a week will usually suffice.  Zinc pyrithione shampoos (e.g. Head and Shoulders) should be used similarly to Selsun.  Ketoconazole shampoo is also effective but is relatively expensive.  Antifungal creams and lotions (e.g. miconazole, etc.) while effective, are awkward (and expensive) to use over larger areas of the trunk.

Oral ketoconazole should not be used as mono-therapy.  This is a common mistake among novice primary care providers.  Although it is very effective in severe cases, it frequently creates complacency in both the physician and patient.  It is not a long term solution and it should be used, if at all, as a "starter" therapy and topical therapy should be used for further treatment.  It is merely an optional adjunct to the topical antifungal therapy above.  Although the literature supports a variety of regiments, one preferred treatment is 200 mg daily for 7 days, taken on an empty stomach.

Written and revised by CAPT Dennis A. Vidmar, MC, USN, Department of Military and Emergency Medicine, and Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, MD (1999).