Shampoo Nizoral: when to use, composition, where to buy

Effects of use

The main direction of action is the elimination of fungal infections that cause seborrheic dermatitis of the scalp, pityriasis versicolor, and dandruff. That is, with regular use of a pharmaceutical product, the effect occurs on the cause of the problem - a yeast-like fungus, and does not simply eliminate external unpleasant symptoms.

Also thanks to shampoo treatment:

• scalp itching and flaking are reduced;
• the spread and activity of the fungus stops;
• addiction is not formed;
• provides prevention of dandruff;
• hair loss stops;
• a positive result is noticeable after 14 days of use.

Tinea versicolor: possibilities of using shampoo containing ketoconazole and zinc pyrithione

Pityriasis versicolor (pityriasis versicolor) is a common superficial skin lesion caused by lipophilic fungi of the genus Malassezia [1]. Fungi of this genus are the only representatives of the fungal kingdom that are commensals of normal human skin [2]. It is believed that at least 90% of the entire population of the Earth are carriers of Malassezia, and approximately up to 10% of the planet's inhabitants are affected by it, although the disease is considered opportunistic and not contagious. The intensity of colonization changes with age: it is extremely low in newborns and then gradually increases towards puberty, as the activity of the sebaceous glands increases [3]. In the population, the incidence statistically depends on: – age (peak incidence is at the age of 14–40 years) [2]; – gender differences (men get sick 1.5–2 times more often) [2]; – the presence of concomitant diseases of the gastrointestinal tract, endocrine disorders, vegetative diseases, immunodeficiencies of various etiologies [2]; – geographic latitude (in temperate climates – about 2%, in tropical climates – up to 40% of the total population) [4]; – professional activity of patients (in persons engaged in physical labor and sweating heavily) [3]; – hereditary predisposition [1]. The above factors significantly influence the composition of the sweat-fat mantle. A change in the chemical composition of sebum, favorable for the fungus, is an increase in the concentration of oleic, palmitic, linoleic, linolenic, stearic, and myristic fatty acids [2]. The favorite place of localization is the skin of the chest and back; less often, elements are noted on the skin of the neck, abdomen, lateral surfaces of the torso, and the outer surface of the shoulders. In addition, rashes can be found on the scalp, but without affecting the hair, sometimes in the groin folds and axillary areas. The disease is manifested by the appearance of pinkish-brown spots with slight pityriasis-like peeling without inflammation and subjective sensations (rarely - slight itching). Merging, the spots can form quite large lesions with scalloped borders. Their color gradually becomes darkish brown. The spots do not protrude above the skin level, and their surface is covered with small pityriasis-like scales. Insolation and ultraviolet irradiation have a detrimental effect on the colonies of the pathogen, and the skin under them does not tan, and white spots (pseudo-leukoderma) appear against the background of a general tan [5]. In addition to the classic course, there are also atypical forms of lichen versicolor: erythematous-squamous, lichenoid, urticaria-like, erythrasma type, vitiligo, diffuse, circinate, as well as special forms: Malassezia folliculitis and the so-called black form [2]. A study of the clinical forms of lichen versicolor shows that the most common (≈90%) is the classical form of the disease, less often - atypical clinical variants of lichen versicolor. The widespread form of the lesion (≈80%) and typical localization of the rash (≈90%) predominate. Knowledge of atypical clinical variants and localizations of pityriasis versicolor is necessary for timely diagnosis and effective treatment of the disease [6]. Verification of the diagnosis is carried out: • anamnestiically; • according to the clinical picture; • detection of hidden peeling of the skin (Balzer test with 5% iodine solution); • microscopy of scales from lesions; • using examination under the rays of a Wood's lamp [1, 7]. Tinea versicolor is usually well treated with topical antimycotics. The US FDA has not approved any systemic drugs for its treatment for a long time, even though some of these drugs have already been included in clinical guidelines [8]. Among the traditionally used treatment methods, such as Demyanovich treatment are not currently used, and antiseptics such as 2% alcohol solution of iodine or 2% salicylic alcohol are used along with modern antimycotics. Along with antifungal creams, ketoconazole in the form of 2% shampoo should be noted. The use of external forms that allow covering a significant surface of the body is of no small importance in the treatment of lichen versicolor. Even with individual small lesions, it is recommended to treat all areas where lichen versicolor usually develops. The shampoo is used once a day for 5 days [9]. Ketoconazole in the form of shampoo as a drug for the treatment of lichen versicolor was included in the clinical recommendations of the 2010 RODVC [10] and is widely used in world practice [11].

But there are also some features of the mycosis under study, which increasingly force one to turn to systemic and combination therapy. First of all, these are recurrent, widespread and atypical forms of the disease, as well as cases of failure of local therapy. The most important problem of local therapy is the impossibility of 100% visual control of the treatment of lesions, since the pathogen can remain in subclinical quantities in places that patients do not treat during treatment for various reasons. This is especially true for men, who are initially generally recognized to be less compliant with external therapy, although they get sick more often. Therefore, the level of relapses of lichen versicolor is at least 20% after local treatment, and, according to some data, the number of patients with relapses of this pathology after treatment varies from 60% in the first year of observation to 90% over 2 years, more often with immunosuppression, excessive sweating, the presence of seborrhea, etc. [12, 13]. Complex treatment with local antifungal agents: cream + shampoo (as a shower gel), as well as combination therapy with systemic and local drugs using antifungal shampoo is one way to solve this problem. Along with the main one, at the second stage, preventive maintenance local therapy is required using shampoo 1-2 times a week. [9, 12], mainly after episodes of severe sweating. The establishment of the dependence of the clinical manifestations of mycotic infection on the composition of the sweat-fat mantle has led to the fact that in recent years, shampoo with a combination of zinc pyrithione and ketoconazole has become more actively used in the treatment of patients with Malassezia infection (including pityriasis versicolor) and associated skin diseases [14]. It has been shown that the use of drugs with a sebostatic effect reduces the likelihood of relapses in Malassezia-associated skin diseases [15].

Zinc pyrithione and ketoconazole are included in Keto Plus shampoo (Glenmark Pharmaceuticals Ltd., India). Ketoconazole, like all azoles, inhibits the biosynthesis of ergosterol and has a fungistatic effect in low concentrations, and has a fungicidal effect in higher concentrations - 2%, as in shampoo. Zinc pyrithione has antiseptic, drying, keratoregulating, sebostatic and anti-inflammatory properties. The combined action of the components of Keto Plus shampoo mutually potentiates the effectiveness of therapy. A treatment option has also been proposed, where instead of a 5-day period of use of shampoo, a 2-week period is used, followed by a transition in the case of common forms to preventive use with the application of 1 r./week. for a long period of time in order to increase the reliability of the regimen and reduce the likelihood of relapses [16]. In our practice, we have been using Keto Plus shampoo for the treatment of lichen versicolor since 2009 [17], and during this period we have accumulated sufficient experience in its use both in primary treatment regimens and at the preventive stage. Giving preference to combination regimens using systemic itraconazole (200 mg once a day for 7 days) or an integrated approach using modern topical antifungal drugs in the form of a cream or solution (1-2 times a day for 1-3 weeks. depending on the drug), we almost always, in addition to such treatment, recommend a combination of zinc pyrithione and ketoconazole in the form of shampoo as a shower gel for the entire duration of therapy in the patient’s usual hygienic regimen (optimally 1 time per day). The use of shampoo containing ketoconazole and zinc pyrithione was assessed positively by patients: the texture and smell of the shampoo are pleasant, it foams well, so we began to recommend it instead of cosmetics. In addition, it must be taken into account that most cosmetic shampoos, shower gels and soaps often have a slightly alkaline pH value, and excessive alkalization of the skin creates more favorable living conditions for fungi of the genus Malassezia, which is excluded if replaced with a special Keto Plus product. If the use of shampoo as a drug for treatment in the practice of dermatovenerologists already occupies a worthy place (both in monotherapy and in complex therapy with local antifungal agents), then information about its use for secondary prevention in individuals prone to relapses is rare [16]. We have accumulated sufficient experience in such use, primarily in risk groups: young people who sweat frequently, who are actively involved in physical education and sports, as well as among law enforcement officers who are forced to wear multi-layered warm clothing for a long time. We present the results of our observations. Purpose of the study: to develop approaches to secondary prevention for lichen versicolor in people prone to relapses, using shampoo containing a combination of ketoconazole and zinc pyrithione. Materials and methods: the work was carried out in conditions of predominantly outpatient dermatological appointments in the period from 2011 to 2015. The study included 62 people aged 21 to 36 years, who underwent annual medical examination and had at the time of inclusion at least the second episode of the disease in 3 years, whose skin condition and the occurrence of relapses could be assessed within a period of at least 2 years after the course of combination therapy according to the scheme indicated above. Therapy was continued until complete clinical resolution. Men made up the majority - 55, women were 7 people. The diagnosis before the course of treatment was verified anamnestiically, clinically, Balzer test, laboratory, the clinical form in 45 patients was quite common. HIV infection was excluded in patients. After completion of treatment, it was recommended to use shampoo with a combination of ketoconazole and zinc pyrithione (Keto Plus, Glenmark, India) as a shower gel for prophylactic purposes. Method of application: the shampoo is worn with the formation of foam on wet skin during the shower from the hair to the level of the pelvis, if necessary, lower, and is not washed off for 5-6 minutes, after which the patient is quickly rinsed. The procedure was recommended to be carried out at least 1 time per week, and if episodes of intense sweating occur, even after such episodes, but not more than 3 times per week.

Results and discussion: of the 62 people whose history was tracked during the observation period, 17 patients did not comply with the instructions and stopped using the shampoo immediately after completing the course of therapy. This group was no less interesting than the groups in which patients used Keto Plus shampoo for prevention, and it was assigned the role of a control group. The first group, in which Keto Plus shampoo was used for more than six months but less than a year, included 31 participants. The second group, where patients reported using Keto Plus shampoo for 2 years according to the recommended preventive regimen, included 14 patients.

In the control group that did not receive preventive therapy, relapses at different times during the observation period were noted in 6 (≈35%) people, while common forms of infection reappeared in 2 patients. In the first observation group, in which the period of preventive use of shampoo was from six months to 1 year, no relapses were noted during the period of preventive use of Keto Plus shampoo. The appearance of clinical manifestations of lichen versicolor was observed in 6 patients over a period of at least 8 months. after completing a course of preventive use of shampoo, mainly in the autumn-winter period, they were represented by single typical colonies on the skin of the trunk or neck. The percentage of relapses in the first group was ≈16%, which is more than 2 times less than in the control group. In the second observed group, which used Keto Plus shampoo in the recommended preventive regimen, there were no relapses of the disease continuously throughout the observation period, i.e. for at least 2 years. Patients in this group positively noted the appearance of a large package of shampoo (150 ml instead of 60 ml), which was regarded by patients as an economically advantageous offer, and we, in addition, assessed it as increasing patients’ compliance with the preventive regimen. I would like to note that both during the main course of therapy and during periods of long-term preventive use of Keto Plus shampoo, there were no cases of individual intolerance, either by subjective or objective indicators.

Conclusions: Our observational study clearly demonstrates the effectiveness and safety of a shampoo containing a combination of ketoconazole and zinc pyrithione as a means for secondary prevention of tinea versicolor in the recommended regimen, especially in individuals predisposed to the disease. Unfortunately, the refined contingent of selected patients, small samples and not very long follow-up periods do not allow us to make population-based, statistically based conclusions about the timing of such preventive therapy. We are cautious about recommendations for many years of continuous use of shampoo with a combination of ketoconazole and zinc pyrithione throughout the peak period of the disease, limited, for example, as indicated above, to the age of 40 years. We have formed the opinion that a two-year period of preventive continuous use of Keto plus shampoo in a regimen of at least 1 rub./week, and in the event of episodes of intense sweating - and after such episodes, but not more than 3 rub./week., is quite sufficient for disease control. Based on clinical experience with the use of such a regimen, we can conclude that preventive treatment after the main course of therapy reduces the likelihood of relapses. In some cases, namely, if in some individuals the tendency to relapse of lichen versicolor persists after discontinuation of the prophylactic use of shampoo, it will be more economically profitable to carry out a repeated course of the main treatment, but again with a subsequent repetition of a two-year course of anti-relapse therapy, rather than continuous preventive use throughout the entire peak period of illness.

Thus, in modern conditions, in the arsenal of dermatologists and mycologists there is an effective local component of the treatment of versicolor versicolor in the form of easy-to-use Keto Plus shampoo, which is an etiopathogenetic combination of ketoconazole and zinc pyrithione as a shower gel. It is especially advisable to use it in common, recurrent and atypical forms of the disease, both in combination with systemic drugs and in complex use schemes together with local antifungal creams (solutions) to increase the effectiveness of treatment of lichen versicolor and prevent (reduce the likelihood) of relapses of the disease. In addition, Keto Plus, due to its pronounced antifungal, antiseptic, drying, sebostatic and anti-inflammatory activity, can be recommended for the preventive treatment of lichen versicolor after the main course of treatment 1-2 times per week. lasting up to 24 months. And the unique pharmacological properties of Keto Plus, combined with ease of use, safety (good tolerability) and pleasant organoleptics, give hope for high patient compliance with the prescribed treatment and prevention regimens.

Literature 1. Klimko N.N. Mycoses: diagnosis and treatment. Guide for doctors. 2nd ed. M.: VG Group, 2008. P. 114. 2. Yakovlev A.B., Suvorova K.N. Malassezia is an infection of human skin. Academic method. allowance. M.: GOU DPO RMAPO, 2005. 3. Sergeev A.Yu., Sergeev Yu.V. Fungal infections. Guide for doctors. 2nd ed. M.: BINOM Publishing House, 2008. pp. 230–238. 4. Fitzpatrick T., Johnson R., Wolfe K. et al. Dermatology. Atlas-directory. Per. from English M.: Praktika, 1999. 5. Tarasenko G.N., Tarasenko Yu.G. Fundamentals of practical mycology. M.: OASIS-Design, 2008. pp. 29–34. 6. Abdulloeva M.A., Zoirov P.T. Clinical forms of versicolor versicolor // Healthcare of Tajikistan. 2011. No. 4. pp. 12–15. 7. Arabian R.A., Klimko N.N., Vasiliev N.V. Diagnosis of mycoses. St. Petersburg: Publishing house SPbMAPO, 2004. pp. 60–62. 8. Wolfe K., Johnson R., Surmond D. Dermatology according to Thomas Fitzpatrick. Atlas-directory. Per. from English M.: Praktika, 2007. pp. 834–837. 9. Sergeev Yu.V., Shpigel B.I., Sergeev A.Yu. Pharmacotherapy of mycoses. M.: Medicine for everyone, 2003. pp. 137–138. 10. Dermatovenerology - 2010. Clinical recommendations (Russian Society of Dermatovenerologists) / Ed. A.A. Kubanova. M.: DEX-Press, 2010. pp. 299–301. 11. Wolf K., Goldsmith L.A., Katz S.I. and others. Fitzpatrick’s dermatology in clinical practice: in 3 volumes; lane from English; total ed. A.A. Kubanova. M.: Panfilov Publishing House; BINOMIAL. Knowledge Laboratory, 2012. Vol. 3, 2013. pp. 1995–1998. 12. Ustinov M.V., Sirmais N.S. Systemic therapy of pityriasis versicolor // Polyclinic. 2014. No. 1. P. 80–83. 13. Faergemann J. Pityrosporum infections // J. Am. Acad. Dermatol. 1994. Vol. 31 (Suppl. 1). P. 18–20. 14. Kudryavtseva E.V. Malassezia infections in the practice of a dermatologist // Advances in medical mycology. T.13. M.: National Academy of Mycology, 2014. pp. 118–120. 15. Albanova V.I., Kalinina O.V. Seborrheic dermatitis of the scalp: the role of Malassezia // Advances in medical mycology. T.14. M.: National Academy of Mycology, 2015. pp. 11–13. 16. Abidova Z.M., Shorahmedov Sh.Sh., Alimzhanov D. Study of the clinical effectiveness of ketoconazole shampoo // Advances in medical mycology. T.11. M.: National Academy of Mycology, 2013. pp. 121–123. 17. Ustinov M.V. Treatment of recurrent common forms of lichen versicolor // All-Russian scientific and practical conference “Current issues of dermatology and urogenital pathology”. Abstract. reports. M.: FMBA of Russia, FGOU IPK FMBA of Russia, 2009. pp. 48–50.

How to use correctly

For Nizoral to work, it must be used correctly. To do this, apply shampoo to hair moistened with water, lightly rub into the skin and leave for at least five minutes. Then the composition is washed off under running water.

Treatment options:

• for manifestations of pityriasis versicolor - apply daily for five days;
• for manifestations of dandruff or seborrheic dermatitis - twice every seven days for two to four weeks.

Prophylactic use involves:

• use once three days in a row in a course on the eve of the start of the summer season to prevent pityriasis versicolor;
• apply once every 7 or 14 days to prevent relapse of seborrheic dermatitis and dandruff.

During use, you should be careful not to get the shampoo on your eyes, otherwise severe eye irritation and excessive tearing will occur. If trouble does occur, rinse your eyes with plenty of water.

If, after washing your hair with Nizoral, your hair feels stiff and dry, then you can apply a conditioner along the length and ends. When undergoing a course of treatment, it is not recommended to apply cosmetics to the scalp.

Use during pregnancy, breastfeeding and childhood

When applied to the hair, the composition is not absorbed through the top layer of the skin, and the likelihood of entering the circulatory system is low. However, there have been no serious studies on the effects of ketoconazole on the health of pregnant women and the fetus, as well as breastfeeding women and infants. Therefore, there is no information about the risks of using shampoo in these categories of patients.

They are supposed to be minimal. If there is an urgent need to use Nizoral, you should consult your doctor to weigh the risk to the fetus and the benefit to the woman.

Shampoo is approved for use by children from 12 years of age; for ages below this limit, the safety of the product has not been established.

Reviews

On the Internet there are positive reviews of Nizoral shampoo from both specialists and patients.

Cosmetologists and trichologists note effectiveness for seborrheic dermatitis already at the beginning of use, including in adolescent patients.

Patients like the absence of a pungent odor, noticeable results from the third use - itching is eliminated, the scalp is healthier, and oily scales disappear. Users also note the economical consumption of the product and the absence of dry scalp after use. The disadvantages include the high price, but analogues with a lower price do not always give the desired effect.

Pityriasis versicolor

Pityriasis versicolor (syn.: versicolor, pityriasis versicolor, pityriasis furfuracea) is a fungal skin disease characterized by damage to the stratum corneum of the epidermis. The causative agent of this disease is the fungus Pityrosporum orbiculare or P. ovale. However, the question of whether both of these forms represent one organism at different stages of its development or are separate species has not been fully resolved. It is currently accepted that both micromorphological varieties P. orbiculare and P. ovale represent different stages in the life cycle of the fungus. Moreover, its oval shape - P. ovale - is more often found on the skin of the scalp, and its round shape - P. orbiculare - on the skin of the body [25]. The correct taxonomic identification of the lipophilic yeasts causing this disease is still a matter of debate. Some scientists prefer the name Pityrosporum orbiculare, while others prefer Malassezia furfur. Thanks to molecular technologies, 10 species of the genus Malassezia have now been identified. Ogunbiyi AO and George AO (2005) identified the most common Malassezia species: M. furfur, M. symboidalis, M. obtusa, M. globosa, M. restricta, M. slooffie and M. pachydermatis [12, 15, 17].

As a result of their analysis, it was established that the cause of pityriasis versicolor in humans is most often M. globosa. Hort W. et al. (2006), having examined 112 patients diagnosed with seborrheic dermatitis, atopic dermatitis, lichen versicolor and AIDS, found that these patients had various types of Malassezia fungi. According to the authors, M. globosa was the most pathogenic species and was more often recorded in HIV-positive patients and patients with lichen versicolor. In the group of patients with seborrheic dermatitis, along with M. globosa, M. sympodialis was isolated.

The issue of the contagiousness of the fungus has been discussed in the scientific literature for quite a long time. Previously, it was believed that transmission of infection occurs either through direct contact with a sick person or through contaminated underwear. This observation was based on the high prevalence of this disease among individuals in the same family. However, it has now been proven that lichen versicolor is not contagious, and a genetic predisposition to the development of keratomycosis has been established: known cases of familial disease are explained by similar skin type in family members who are consanguineous [6, 25, 28].

The causative agent of lichen versicolor is isolated from 10–15% of the population, and 2 times more often in men. The disease mainly develops between the ages of 15 and 40 years. This mycosis is characterized by deterioration in the summer, cases of spontaneous recovery are possible. In some patients, the disease becomes chronic and prone to relapse. However, in most cases, P. orbiculare (ovale) exhibits its pathogenic properties only in adolescence [1, 2, 6, 9]. P. orbiculare (ovale) is a lipophilic fungus, so the intensity of skin colonization is related to the function of the sebaceous glands. In particular, in children under 5 years of age the fungus is not detected at all, while in 15-year-olds it is detected in 93% of cases. Further, with age, the percentage of detection of P. orbiculare decreases, which once again confirms the assumption of a relationship between the presence of the fungus and the functional activity of the sebaceous glands [6, 26]. The primary location of keratomycosis is the mouth of the pilosebaceous follicles; here the fungus multiplies, forming colonies in the form of yellowish-brown dots. Fungi concentrate around the sebaceous glands, using their secretions as a source of fatty acids necessary for their growth and development. Increased air humidity also contributes to the pathogenicity of the fungus, as evidenced by the high prevalence of lichen versicolor among the population of tropical and subtropical countries. Thus, the incidence rate in temperate climates is 2%, in tropical and subtropical climates - up to 40% of cases [6, 16, 19, 24, 26].

Being a yeast-like fungus, P. orbiculare has many of the qualities inherent in this group of fungi. In particular, the disease develops when a saprophytic form is transformed into a pathogenic one under special, favorable circumstances. The development of the disease is promoted by: increased sweating, seborrhea, decreased physiological peeling of the skin, decreased nutrition, and pathology of internal organs. Lichen versicolor is a unique marker of diabetes mellitus, tuberculosis, rheumatism, and AIDS. In these diseases it is found in 52–63% of patients. If pityriasis versicolor develops against the background of tuberculosis, lymphogranulomatosis and other diseases accompanied by sweating, there are no age restrictions and clinical signs of this dermatosis can be observed at any age [6]. The literature describes a case of lichen versicolor diagnosed in a three-month-old child with leukemia [23].

In recent decades, hematogenous infections caused by M. furfur have been observed; they have been described in weakened and immunosuppressed patients, especially after organ transplantation, as well as in neonatal children receiving lipids through a central venous catheter [1, 11, 13, 24].

The presence of cross-reacting antigens in P. orbiculare with fungi of the genus Candida provokes the development of allergic reactions of immediate, immunocomplex and delayed types. Studies conducted by various authors have proven that one of the main risk factors for the formation of complicated forms of atopic dermatitis at an early age in children is the predominance of fungi of the genus Malassezia. The addition of an associated fungal infection changes the clinical picture of atopic dermatitis, which is characterized by a more severe course, widespread process and resistance to traditional therapy [10, 16, 27]. According to the observations of Mayser P. et al. (2000) in patients with P. orbiculare colonization on the scalp and neck, specific IgE antibodies were more often recorded than in patients with localization on the skin of the trunk. In addition, the author found that patients with Malassezia more often complained of diffuse hair thinning.

There is evidence to support the role of P. orbiculare in the development of seborrheic dermatitis. As a result of their vital activity, these fungi break down sebum triglycerides into free fatty acids, and these, in turn, are the direct cause of dermatitis on the surface of the skin, but this assumption still requires proof [8]. In particular, an experimental model of seborrheic dermatitis was obtained by rubbing a P. orbiculare culture into the skin of subjects. Subsequently, regression of experimental dermatitis was noted under the influence of various antimycotic drugs, which confirmed the etiological role of P. orbiculare in seborrheic dermatitis. Moreover, if normally the microflora of the scalp contains 46% of this fungus, then with dandruff it consists of 74% of them, and with seborrheic dermatitis the number of fungi reaches 83% [6, 28].

It must be remembered that seborrheic dermatitis associated with P. orbiculare (ovale) may be the single earliest manifestation of AIDS. According to foreign authors, from 30% to 80% of patients with HIV infection have seborrheic dermatitis, compared to healthy young people in whom this dermatosis was diagnosed only in 3–5% of cases. AIDS-associated seborrheic dermatitis is characterized by resistance to therapy and papular rashes resembling psoriasis [1, 8, 9, 13].

Clinical picture of the disease. The onset of the disease is characterized by the appearance of yellowish dots confined to the mouth of the hair follicles. The primary morphological element is a pink-yellow spot, gradually changing to brown-yellow, on the surface of which there are pityriasis scales. The elements are characterized by peripheral growth and, subsequently, fusion into larger lesions with scalloped edges. With a long course of mycosis, the lesions can occupy large areas of the skin. Over time, the color of the lesions can vary from white to dark brown, this served as the basis for the second name for lichen - multi-colored. The surface of the rash is covered with pityriasis-like scales, which are hardly noticeable upon superficial examination, but when scratched, peeling easily occurs (Beignet's symptom). Since the favorite localization is confined to the “seborrheic zones,” the upper half of the body and the scalp are affected. Additional diagnostic criteria, well known to doctors, are the Balzer iodine test and a golden-yellow or brownish glow under a Wood’s lamp, as well as detection of the pathogen during microscopic and cultural studies [1, 2, 5, 6, 9].

A feature of the clinical picture of pityriasis versicolor is the presence of pseudoleukoderma. Scientists have divided opinions about the causes of uneven skin coloring in this dermatosis. Some researchers believe that P. orbiculare (ovale) inhibits tyrosinase activity during the oxidation process, which leads to a decrease in melanin synthesis and is clinically manifested by the occurrence of true leukoderma [6]. According to other authors, the loosened stratum corneum on the lesions prevents the penetration of ultraviolet rays into the depths of the epidermis. Therefore, after removal of scales during water procedures, the affected lesions become lighter than the surrounding healthy skin [2, 9].

As a rule, diagnosis is not difficult, but there are several points that the practitioner needs to pay attention to. Firstly, in individuals who received treatment and were irradiated with ultraviolet rays, the Balzer test will be negative. Secondly, identifying affected areas on the scalp is of practical importance: if the doctor does not pay attention to this localization of keratomycosis, then there is a high probability of relapse. To diagnose lesions on the scalp, a Wood's lamp is used (the lesions have a greenish-yellow, yellowish-brown or brownish glow). Thirdly, pinkish-brown spots are barely noticeable on white skin, so they are often ignored when examined, but in the summer, if you have a tan, they become more noticeable. And the last nuance: in people without immune deficiency, isolated spots do not exceed, as is known, 1–1.5 cm in diameter, but with severe immunodeficiency they can reach 5 cm in diameter. In this case, not only a disseminated character is noted, but also rich pigmentation and infiltration of elements of multi-colored lichen. In patients with AIDS, lichen versicolor more often manifests itself as seborrheic dermatitis, less often as atopic dermatitis and multiple folliculitis in areas of the skin with symptoms of vasculitis and a necrotic component.

The atypical course of lichen versicolor was described by various authors [11, 14]. The rarest manifestations of lichen versicolor include lesions on the skin of the soles. In the domestic literature, such localization is reported by V. M. Rukovishnikova (1999), who in her monograph refers to the observations of V. P. Zhirkova (1977) of a 16-year-old boy with hyperhidrosis, who, along with rashes of multi-colored lichen in typical places (chest , back, neck, face) there were foci of mycosis on the soles. A pronounced torpidity of the lesions of this unusual localization was noted. Even after four months of treatment, non-inflammatory brownish spots of irregular shape and outline remained on the heels and in the transitional fold from the toes to the sole.

Differential diagnosis of pityriasis versicolor is carried out with syphilis (with syphilitic roseola and leucoderma). The diagnosis of syphilis is confirmed by positive results of classical serological tests (CSR), Treponema pallidum immobilization test (TPI), and immunofluorescence test (RIF). In addition, roseola in secondary syphilis has a pinkish-livid tint, disappears with diascopy, does not peel off, does not fluoresce in the light of a fluorescent lamp, and the Balzer test is negative.

In syphilitic leukoderma there are no confluent hyperpigmented spots and micropolycyclic edges. Syphilitic roseola is characterized by a predominant localization on the trunk and upper extremities, which determines some similarity in the clinical picture, however, with syphilitic lesions there is no tendency to growth and fusion of elements. The roseola spot is of vascular origin, there is no peeling, it is not accompanied by subjective sensations, the Balzer test is negative.

Lichen versicolor should be distinguished from pink lichen of Zhiber, in which erythematous spots are acutely inflammatory, round or oval in shape, with a peculiar peeling in, there is a “maternal” plaque. The rashes are located symmetrically along Langer's lines. The edges of the central, flaky part of the plaque are surrounded by a collar of scales. Numerous secondary rashes are visible around the maternal plaque.

Pityrosporum folliculitis (Malassezia folliculitis) is an infection of the hair follicle caused by yeasts, the same ones that cause pityriasis versicolor. This disease is a separately located, sometimes itchy papulosquamous rash, localized mainly on the upper half of the body and shoulders. Pityrosporum folliculitis most often affects young and middle-aged people and women. Follicular occlusion appears initially, which is secondarily accompanied by increased growth of the fungus. Predisposing factors are diabetes mellitus, as well as taking broad-spectrum antibiotics or corticosteroids. The condition can appear on the forehead and mimic persistent acne. The clinical picture consists of asymptomatic or slightly pruritic dome-shaped follicular papules and pustules with a diameter of 2–4 mm. This dermatosis is more common in the tropics, where it manifests itself as follicular papules, pustules, nodules and cysts. A distinctive feature of Pityrosporum folliculitis is the absence of comedones, torpidity to therapy and localization in the forehead. According to Thomas P. Habiff (2006), very often patients with Pityrosporum folliculitis are mistaken for acne patients. According to the author, this disease should be suspected in young and middle-aged patients with follicular lesions located on the trunk and complaints of itching.

Treatment. Since this disease develops when the saprophytic form of the fungus is transformed into a pathogenic one under special, favorable circumstances, it is necessary, first of all, to identify the provoking factors. Lichen versicolor is a marker of diabetes mellitus, tuberculosis, rheumatism, and AIDS. Therefore, when examining a patient, it is necessary to conduct appropriate studies. Particular attention should be paid to persons who do not fall into the age category from 15 to 45 years. Often the development of a persistent clinical picture of pityriasis versicolor is caused by chemotherapy in cancer patients. As a rule, after completing the course of intensive treatment, such patients undergo spontaneous self-healing.

As mentioned above, pityriasis versicolor is characterized by damage to the surface layer of the epidermis - the stratum corneum. Therefore, treatment of keratomycosis should begin with external means. Medicines for the treatment of pityriasis versicolor can be divided into several groups:

• keratolytic agents;
• fungicidal preparations;
• products containing zinc pyrithioneate;
• combined means.

Therapy for lichen versicolor depends on the prevalence and location of the lesions. Previously, keratolytic agents were used in the treatment of this mycosis: 2–5% salicylic alcohol or an alcohol solution of resorcinol 2 times a day. Modern methods of therapy include fungicidal drugs from the azole group. It has been established that under the influence of antimycotic drugs, after 24 hours, dehydration and vacuolization of the cytoplasm in the fungal cell occurs, the cell wall clears, from which after 48 hours only a shadow remains. Therefore, specific antifungal treatment is often preferred over keratolytic drugs.

Considering the superficiality of skin lesions with keratomycosis, it is preferable to use fungicidal agents in the form of solutions (clotrimazole, bifonazole, ciclopirox, naftifine (Exoderil), terbinafine (Lamisil)) or econazole in powder form, sold under the trade name "Ifenek", which is applied to the affected areas of the skin and rub lightly. A more convenient form of using the drug is a spray (Lamisil, Thermikon). All antimycotic solutions for the treatment of pityriasis versicolor are prescribed 2 times a day for 1 week. Ketoconazole has higher activity against P. ovale, inhibiting its growth in concentrations 25–30 times lower than other antifungal drugs and several times lower than any systemic antimycotics. When topical forms of ketoconazole are applied to the skin, effective concentrations remain inside and on the surface of the epidermis for 72 hours after discontinuation of the drug, which is explained by the affinity of the drug for keratinized tissues.

Zinc pyrithione also has a direct antifungal effect. Today, the mechanism of therapeutic effects of zinc pyrithione is associated not only with cytostatic, but also with antifungal and antimicrobial effects. The effectiveness of drugs containing zinc pyrithione against yeast-like fungi has been studied by many authors [1, 3, 4]. These drugs include Psorilom and Skin-cap, produced in two forms: spray and cream. In the future, these drugs can be used by patients as prophylactic agents at least once every 2 weeks. While inferior to ketoconazole, zinc pyrithione has superior antifungal activity to other drugs, including selenium sulfide and some imidazoles. In the last decade, zinc-based shampoos (Head and shoulders, Friederm zinc) have been widely used in the treatment of dandruff. Thus, the most effective drugs in the treatment of pityriasis versicolor are antifungal agents and zinc pyrithione.

When the scalp is affected by fungus, medicated shampoos containing fungicidal agents (Nizoral, Sebazol, Ducre Quelual DS, Ketoconazole) are used, which are prescribed daily with an exposure of 2–5 minutes for 7–10 days. Treatment with shampoos containing tar (Psoril) is effective in the presence of seborrheic dermatitis to eliminate such manifestations as infiltration, swelling, peeling, and erythema.

Combined preparations include shampoos: Node DS plus, which contains salicylic acid, climbazole, zinc pyrithione, and Keto plus based on ketoconazole and zinc pyrithione.

Systemic treatment is indicated for patients with advanced disease who do not respond to topical therapy or who experience frequent relapses. Intraconazole is prescribed at a dose of 200 mg 2 times a day for one day or 200 mg every day for 5 days. The drug is taken with food to improve absorption. Ketoconazole is taken in a dose of 400 mg once or 200 mg daily for 5 days at breakfast with fruit juice. Fluconazole is prescribed at a dose of 150 mg (2 capsules per week for 4 weeks or 2 capsules as an initial dose, repeated after 2 weeks). If the process resolves slowly, the course of systemic antimycotics can be repeated after 2 weeks. The patient is not recommended to take a bath for 12 hours after treatment, since abstaining from water procedures allows the medicine to accumulate in the skin. Some authors recommend changing clothes daily for one month to prevent relapses. Patients must accept that residual hypopigmentation, as a consequence of pseudoleukoderma, lasts for quite a long time.

In the treatment of Pityrosporum folliculitis, one should adhere to the same principles as in the treatment of pityriasis versicolor, but it is preferable to combine systemic ketoconazole (200 mg daily for 4 weeks) with external antifungal agents.

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Yu. A. Gallyamova, Doctor of Medical Sciences, Associate Professor

GOU DPO RMAPO, Moscow

Contact information for authors for correspondence