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Nov 02, 2021
5 min read

What is fungal acne? Symptoms, causes, treatments

Fungal acne comes from the Malassezia yeast that normally lives on the skin. It is not true acne, and common acne treatments often make it worse. You can have both types of acne at the same time. Fungal acne breakouts are often itchy and made up of small bumps, usually on the chest, back, and shoulders. Treatment often includes a combination of habit modifications, over-the-counter creams/shampoos, and prescription oral antifungal pills.

Disclaimer

If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

Everyone is familiar with acne. Whether you had it as a teenager or an adult, or you simply know people who have, you’ve likely come across its most common type, acne vulgaris. However, there is another type of skin condition—fungal acne—that healthcare providers sometimes misdiagnose as acne. And that’s a problem, because misdiagnosis often delays finding the right treatment.

A specific type of yeast causes fungal acne, and it can sometimes take on the appearance of acne vulgaris. Read on to learn how to recognize fungal acne, plus how to treat and prevent it.

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What is fungal acne?

A skin yeast called Malassezia causes fungal acne, which is why some healthcare providers refer to fungal acne as Malassezia folliculitis (and used to call it pityrosporum folliculitis). While it may sound unusual to have yeast on your skin, Malassezia and other types of yeast and bacteria are actually a normal part of your skin flora (organisms that grow on your skin). Malassezia typically grows on the skin and doesn’t usually cause a problem—until certain conditions arise, which we’ll discuss below (Cohen, 2014). 

Fungal acne isn’t really acne—it just looks like it. Many people do not receive a fungal acne diagnosis until they try traditional acne treatments and see no improvement. In fact, some common acne treatments, like antibiotics and steroids, can actually make fungal acne worse (Cohen, 2014). 

Because people often confuse fungal acne with typical acne, getting accurate counts of people with Malassezia folliculitis is difficult. However, estimates are that 12% to 27% of people with acne also have fungal acne (Rubenstein, 2014).

Symptoms of fungal acne

Common signs and symptoms of fungal acne include (Rubenstein, 2014): 

  • Itching (in almost 80% of people)
  • Bumps, pimples, papules, and pustules of similar shape and size (1–2 mm)
  • Worsening acne in hot weather 
  • Breakouts more on the chest, shoulders, and back than on the face
  • Other concurrent Malassezia-related skin conditions, like seborrheic dermatitis or dandruff 
  • Lack of improvement or worsening with traditional acne therapy

Fungal acne symptoms vs. acne vulgaris

There are some key differences between fungal acne and acne vulgaris. While regular acne is usually scattered, mainly on the face, and the breakouts might have different lesions (whiteheads, blackheads, papules, etc.), fungal acne usually looks like small (1–2 mm) bumps and pustules of similar size and shape. 

Unlike common acne, fungal acne is also usually itchy—almost 80% of people with fungal acne report itchiness (Cohen, 2020). You will commonly find fungal acne on the trunk (shoulders, chest, and back) more often than on the face. When it does occur on the face, it is usually on the chin or the sides, rather than the central parts of the face (like the forehead or nose) as in typical acne (Rubenstein, 2014).

Another difference is that while common acne can affect anyone, old or young, fungal acne typically affects young adults—especially those who live in or who have visited warm, tropical climates (Saunte, 2020).

Despite their differences, fungal acne is often misdiagnosed as common acne. Complicating matters further, it’s possible to have both conditions at the same time, making proper diagnosis key to fully clearing your skin. 

How is fungal acne diagnosed?

How do you know that you have it if there is so much confusion between diagnosing fungal acne and run-of-the-mill acne? Healthcare providers may use a combination of methods to diagnose fungal acne, including (Saunte, 2020):

  • Physical exam: Your provider may be able to diagnose fungal acne by observing its typical appearance, including papules and pustules of the same size and shape, and breakouts that are present more on your shoulders, chest, and back than on the face. 
  • Skin scraping: Scraping the papules and pustules, staining the cells with a specific chemical, and examining them under the microscope may help your dermatologist or healthcare provider visualize the Malassezia yeast.
  • Skin biopsy: More invasive than a scraping, your healthcare provider will remove a small piece of skin and examine it under a microscope to look for the Malassezia yeast.
  • Treatment response: Improvement after treatment with antifungal medication is a good indication that your acne was fungal and not simply common acne vulgaris.

Fungal acne treatment

If you have acne, chances are you’ve tried many different creams, lotions, and more to clear your skin. However, if you have fungal acne, there is a good chance that traditional treatments did not help your acne—and some may have even made it worse. 

But, there is hope! 

Several treatments can effectively improve fungal acne, and dermatologists will often combine fungal acne treatment methods for better results. Your treatment plan may include habit modifications, over-the-counter medications, and prescription drugs. 

Habit modifications

Habit modifications include showering whenever you sweat excessively, changing out of workout clothes right after exercising, and wearing breathable fabrics. All of these changes help to decrease trapped sweat and moisture on your skin. 

We also know that oily skin plays a role in fungal acne—so changing your skincare routine to reduce skin oils can help. Use skincare products that are non-oily and cleanse regularly.

Over-the-counter medications 

Over-the-counter medications can help decrease the fungal population on your skin. However, these anti-fungal creams or lotions can’t get deep into the follicles, so they don’t work very well on their own. Your provider may recommend using them in combination with antifungal pills. Over-the-counter antifungal creams or lotions include (Levin, 2011):

  • Ketoconazole lotion 2% daily
  • Econazole nitrate cream 1% daily
  • Clotrimazole cream 1% daily
  • Selenium sulfide 1% dandruff shampoo used both as shampoo and body wash (e.g., Selsun blue)

Prescription medications

The most effective way to treat fungal acne is with prescription antifungal medicines. Oral antifungal therapy (pills) are best at reaching the yeast deep in the hair follicles, so they are usually what healthcare providers will try first for a few weeks. Once the fungal acne resolves, topical lotions or shampoos and/or an antifungal pill once a week or once a month can keep it at bay (maintenance therapy)—unfortunately, recurrences are common. Prescription medications include (Levin, 2011):

  • Ketoconazole (primary or maintenance therapy)
  • Fluconazole (primary or maintenance therapy)
  • Itraconazole (primary or maintenance therapy)
  • 2.5% selenium sulfide lotion used as shampoo & body wash (maintenance therapy)
  • Ketoconazole shampoo 2% (maintenance therapy)

How to prevent fungal acne

Just like you can’t entirely prevent common acne (you can’t control when your hormones will flare!), you can’t always avoid fungal acne. For example, people with certain medical conditions, like diabetes or HIV, may be more prone to developing fungal acne. 

However, no matter what your situation may be, there are some things that you can do to help prevent the development or severity of fungal acne, including:

  • Shower whenever you sweat excessively.
  • Change out of sweaty clothes right away.
  • Avoid wearing tight-fitting clothes. 
  • Choose breathable fabrics. 
  • Choose non-oily skincare products.
  • Avoid unnecessary antibiotics, whether topical or pills—but be sure to talk to your healthcare provider before stopping any medications.

When to see a dermatologist

If you have fungal acne, changing some habits and trying the over-the-counter treatments above may help it improve. However, if your acne lasts longer than a few weeks, is getting worse or not improving, or makes you feel shy and embarrassed, you should see your healthcare provider. They or a dermatologist will work with you to develop a treatment plan that is right for you.

References

  1. Ayers, K., Sweeney, S. M., Wiss, K. (2005). Pityrosporum Folliculitis: Diagnosis and Management in 6 Female Adolescents With Acne Vulgaris. Archives of Pediatrics and Adolescent Medicine, 159(1), 64–67. doi: 10.1001/archpedi.159.1.64. Retrieved from https://jamanetwork.com/journals/jamapediatrics/fullarticle/485898 
  2. Cohen, P. R., Erickson, C., Calame, A. (2020). Malassezia (Pityrosporum) Folliculitis Incognito: Malassezia-associated Folliculitis Masked by Topical Corticosteroid Therapy. Cureus, 12(1). doi: 10.7759/cureus.6531. Retrieved from https://www.cureus.com/articles/26367-malassezia-pityrosporum-folliculitis-incognito-malessezia-associated-folliculitis-masked-by-topical-corticosteroid-therapy
  3. Jacinto-Jamora, S., Tamesis, J., & Katigbak, M. L. (1991). Pityrosporum folliculitis in the Philippines: diagnosis, prevalence, and management. Journal of the American Academy of Dermatology, 24(5), 693–696. doi: 10.1016/0190-9622(91)70104-a. Retrieved from https://linkinghub.elsevier.com/retrieve/pii/019096229170104A 
  4. Levin, N., & Delano, S. (2011). Evaluation and Treatment of Malassezia-Related Skin Disorders. Cosmetic Dermatology, 24(3), 137–145. Retrieved from https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/024030137.pdf 
  5. Rubenstein, R. M., & Malerich, S. A. (2014). Malassezia (pityrosporum) folliculitis. The Journal of Clinical and Aesthetic Dermatology, 7(3), 37–41. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970831/
  6. Saunte, D., Gaitanis, G., & Hay, R. J. (2020). Malassezia-Associated Skin Diseases, the Use of Diagnostics and Treatment. Frontiers in Cellular and Infection Microbiology, 10, 112. doi: 10.3389/fcimb.2020.00112. Retrieved from https://www.frontiersin.org/articles/10.3389/fcimb.2020.00112/full