Why Fungal Acne Doesn’t Exist: Understanding Malassezia Folliculitis | Ask Doctor Anne

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Let’s talk about why fungal acne does not exist. I hear you, the bumps on your face are very much there and real, but trust me, no matter how many people use the term, fungal acne is not a thing. Malassezia folliculitis on the other hand is, and it is what people mean when they say they have fungal acne.

 

Why fungal acne is not acne
Why fungal acne is not acne

 

But in order to know how to prevent and treat this condition, you need to understand where it comes from – and if you do that, you will see why it is very much not acne.
Let’s talk all things Malassezia folliculitis – what is it, why you get it and how you’ll get rid of it!

 

 

Why is fungal acne not really acne?

First things first, fungal acne isn’t technically acne. Shocking, right?

Traditional acne is caused by bacteria growing in clogged pores, and so called fungal acne, or Malassezia folliculitis, is caused by an overgrowth of yeast in said pores, but without them being clogged. Yes, you heard that right—yeast, like the kind in bread. This pesky fungus thrives on your skin and causes those frustrating tiny bumps.

Acne has by definition comedones, so blackheads and whiteheads. Malassezia folliculitis does not have clogged pores, so no comedones. No comedones, no acne.

 

Malassezia furfur in skin scale from a patient with tinea versicolor PHIL 3938 lores

 

What causes the tiny bumps?

So if the tiny bumps you see on your face are not whiteheads, what are they? They are an inflammation in the hair follicle caused by an overgrowth of Malassezia yeast. Malassezia furfur, often also referred to as Pityrosporum ovale, is present on everyones skin. You all know that we have a skin microbiome made up of different bacteria, fungi and even mites. As long as it is in balance, everythng is fine. But if something offsets this balance and one of the different components starts to grow much more than usual, that often leads to problems. (More info: Everything you need to know about the skin microbiome)

In this case it is that yeast overgrowth paired with a genetic disposition and contributing lifestyle factors. Factors like humidity, sweat, and even some skincare products can create a perfect breeding ground for this yeast.

Imagine them having a little party on your face—annoying, right?

 

Malassezia folliculitis
This is how Malassezia folliculitis looks like
Source: www.dermNet.com

 

What is the difference between Malassezia folliculitis and acne?

It can be hard to spot the difference between Malassezia folliculitis and Acne for the untrained eye. Even for the trained eye there might be difficulties as you can absolutely have both at the same time, meaning the Malassezia folliculitis hides behind the acne.

We already established that the key difference lies in the cause and appearance. Regular acne has clogged pores and can present as lesions of different shapes and forms, think blackheads, whiteheads, or cysts caused by bacteria. Malassezia folliculitis, on the other hand, shows up as monomorphic, meaning mono – one and morphic- shaped, so uniform, itchy bumps caused by a yeast.

The location can be different too, with Malassezia folliculitis often showing up on the forehead or jaw sparing the central face, while acne usually affects the t-zone and spreads from there. Both can show up on the body, especially on chest and back. (More info: The best way to get rid of body acne)

 

Comedones, typical for acne
Comedones, typical for acne
Source: www.DermNet.com

 

How can fungal acne be diagnosed?

Diagnosing Malassezia folliculitis can be tricky. While you can start with a self-assessment—itchy, uniform bumps that don’t respond to acne treatments are a pointer in the right direction —a definitive diagnosis often requires a visit to your dermatologist.

Here is a quick check list for a first impression – not intended to replace a doctors visit!

  • Do you see comedones? Yes for acne, no for Malassezia folliculitis
  • Do the lesions itch? No for acne, yes for Malassezia folliculitis
  • Have you tried acne treatment as recommended by guidelines and for several weeks without seeing improvement? No for acne, yes for Malassezia folliculitis
  • Have you been diagnosed with Malassezia folliculitis in the past before? No for acne, yes for Malassezia folliculitis

But remember, you can have both at the same time!

At the doctors office they will either do a skin scraping to look at it under the microscope or use a special lamp called a Woodlamp that uses UV light and will make the yeast glow – if your skin is extra glowy, you probably have overgrowth.

 

blisters of drugs
Different drugs can increase the risk for fungal acne
Image by Leopictures from Pixabay

 

Who is at risk for getting fungal acne?

Anyone has Malassezia furfur living on their skin, but only certain people react with inflammation, so there is a genetic component that influences your individual immune reaction, so this is the first risk factor – being genetically predisposed.
The second thing you’ll need is overgrowth – Malassezia furfur feeds on your sebum, so the more sebum you produce, the better it can grow – having oily skin is risk factor number two.
I mentioned before that usually the different microbes keep each other in check, so if you reduce some of them, Malassezia has it easier to thrive – topical or systemical antibiotics or harsh cleansing that reduces the bacteria naturally present is the third risk factor.
If you are immunocompromised because you are on steroid medication, ill or have a poorly controlled diabetes, your risk for dysbalances in the skins microbiome increases as well – so a compromised immune system is risk factor number four.

And lastly it is lifestyle factors like living in a humid climate with increased sweating, sweating through exercise that isn’t rinsed off as soon as possible, tight clothing that traps the sweat and sebum and causes friction, all these are risk factors as well. (More info: The best skincare routine pre- and post workout)

Basically, if you live in a sauna and love spandex, you’re a prime candidate.

 

Woman training with weights for well aging
Sweaty exercise increases your risk for fungal acne

 

How can you prevent fungal acne?

You will often hear the recommendation to use “fungal acne safe skincare”, but let me assure you, the role this plays isn’t half as big as it is made out to be. The main factor for Malassezia folliculitis is the sebum in your skin, and that is influenced by genetics and hormones much more than it is through skincare.

Yes, using lighter formulas, especially if your skin is oily and you live in a hot climate, is a good idea, and maybe also stay clear of slugging which will trap not only hydration, but also everything else underneath that layer of vaseline. But banning everything that says “oil” on the label isn’t necessary.

If you want to be extra cautious, experiment with avoiding long chain fatty acids like Olive Oil, but as JLo has shown – skincare is individual. Some might get Malassezia folliculitis when using it, other will look 20 years younger thanks to Olive Oil…

Other than that keep your skin dry and cool, wear breathable fabrics, and wash your workout clothes regularly! While Malassezia folliculitis isn’t contagious – remember, everyone has it on its skin anyway, it can transfer in the person affected from one region to another.

 

Dandruff shampoo with Ketoconazole
Dandruff shampoo for your face? Sometimes that might be a good idea.

 

How can you treat fungal acne?

Treatment involves antifungal medications like ketoconazole or clotrimazole – not antibiotics, as it is not caused by bacteria.

Over-the-counter antifungal shampoos can work as a face wash as they contain Ketoconazole, but depending on their formulation can also be quite harsh on the skin. Don’t use them every day or even twice a day, see if your skin tolerates them four to five times a week and have patience. Nothing will work over night, it will take at least a month to see results. Sometimes the yeast sits to deep in the hair follicle, so the shampoo face wash can’t sufficiently reach it. In this case oral antifungal medication might be necessary, for which you need to see a doctor.

And in other cases you might have a folliculitis, but not one caused by Malassezia – other microorganisms like Staph or gram-negative bacteria can cause that too, and you need a skin swab and a microscope to differentiate that.

So if you have self diagnosed and started treating things at home, but don’t see the results you want despite being consistent over more than a month, go see a doctor! Chances are, you’ll need more than you can get without their help.

Some bad news to end this post: If you had Malassezia folliculitis or “fungal acne” once, you will most likely get it again whenever the stars or in this case the risk factors align. You will never get rid of the yeast completely, and shouldn’t as it is part of your microbiome, so if you are predisposed, any overgrowth will trigger another round.

 

TL;DR

Fungal acne, or correct Malassezia folliculitis, isn’t true acne. It’s caused by yeast, not bacteria, leading to uniform, itchy bumps without clogged pores. It thrives in humid conditions, on oily skin, or due to imbalanced microbiomes often from antibiotics or steroids. Diagnosis often needs a dermatologist, but look for itchy, non-responsive-to-acne-treatments bumps. Prevent it by keeping skin dry, using breathable fabrics, and lighter skincare products. Treatment includes antifungal medications like ketoconazole, but persistent cases may need a doctor’s help. Unfortunately, it can recur due to its nature as part of the skin microbiome.

And there you have it—fungal acne demystified! Got more questions? Drop them in the comments below.

 

Fungal acne explained
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