Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concerns related to tinea versicolor, such as:
Discolored patches on the skin (describe location, color – usually lighter or darker than surrounding skin)
Itching (may or may not be present)
Scaling or flakiness of the affected areas
History of Present Illness:
Onset, duration, and progression of symptoms.
Seasonal variation (may worsen in warm, humid weather).
Any recent history of excessive sweating or tight-fitting clothing.
Use of topical steroids or other medications that may alter skin pigmentation (can worsen symptoms).
Past Medical History:
Underlying medical conditions (e.g., weakened immune system).
History of other fungal infections.
Family History:
Family history of tinea versicolor.
Social History:
Not typically relevant unless related to factors like sweating (e.g., occupation, exercise habits).
Physical Exam:
Vital signs (usually normal).
Skin examination:
Look for well-defined patches on the chest, back, shoulders, upper arms (most common locations).
Assess the color of the patches (hypopigmented – lighter than surrounding skin, or hyperpigmented – darker).
Evaluate for scaling or flakiness of the affected areas.
Diagnostic Tests (usually not required):
Wood’s lamp examination: May reveal a yellow-green fluorescence under Wood’s lamp in some cases, but not always reliable for tinea versicolor.
Microscopic examination of skin scrapings: Potassium hydroxide (KOH) preparation of skin scrapings can reveal fungal elements under microscopy, confirming the diagnosis.
Assessment:
Clinical diagnosis of tinea versicolor based on characteristic history and physical exam findings.
Consideration of the extent of involvement.
Plan:
Antifungal Treatment: Topical antifungal medications (e.g., clotrimazole, miconazole, terbinafine, selenium sulfide) are typically used for tinea versicolor. Shampoos or lotions may be prescribed depending on the location and extent of involvement.
Patient Education:
Explain the fungal cause of tinea versicolor and that it is not contagious.
Instruct on proper application of antifungal medication and the importance of completing the prescribed course of treatment.
Discuss potential lifestyle modifications that may help prevent recurrence (e.g., wearing loose-fitting clothing, showering regularly).
Follow-up: Schedule a follow-up appointment in 1-2 weeks to monitor treatment response and assess the need for additional treatment or adjustments.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. The diagnosis and treatment of tinea versicolor can usually be made clinically, but confirmatory testing may be considered in some cases. Consultation with a healthcare professional is recommended for diagnosis and treatment