Decoding Fungal Acne: Diagnosis, Treatment and Prevention
Have you been treating acne for some time now but don’t seem to notice any changes? Do you have red bumps on your face that feel like acne breakouts but are itchy? Well, you might be dealing with Fungal acne. Let's dive into what it is and what can be done about it.
First, Fungal acne isn’t acne at all, but Folliculitis, caused by Malassezia yeast present in normal skin flora. Malassezia (Pityrosporum) folliculitis also known as MF, is a benign disorder that is caused by commensal fungi becoming pathogenic when the immune system is disturbed . Condition is commonly misdiagnosed as normal acne even by professionals, which leads to many years of inappropriate and prolonged treatment.
Image 1: Malassezia folliculitis (Oakley, 1997).
As of today, 14 different Malassezia species are known, each causing different skin problems, such as Pityrosporum Folliculitis, Dandruff, and atopic dermatitis a.k.a eczema .
This yeast is a normal inhabitant of our skin, but why does it cause problems in some people but not in others? There are some internal and external risk factors associated with developing Fungal acne, such as high sebum production, sweating, antibiotic usage, and humid climate.
Research also shows that adolescents have a higher chance of developing Pityrosporum folliculitis because of overactive sebaceous glands . While some studies indicate that females are more prone to developing Fungal acne, others report predominance in males .
What is the difference between normal acne and Pityrosporum folliculitis?
As mentioned in the beginning, MF is usually incorrectly diagnosed as acne vulgaris or even Bacterial folliculitis. These acne-like lesions are extremely itchy and stubborn to treat. Monomorphic in form (usually 1 or 2 mm in size) they commonly occur on the upper back, chest, shoulders, and face. Most often it does not respond to acne medication, however, some ingredients are good for both conditions. 
Unlike acne MF is caused by Yeast and not bacteria, therefore it cannot be treated with antibiotics, usually prescribed for acne. It is important to differentiate between these two conditions because the improperly prescribed medication might worsen the patient’s skin condition.
How can it be treated?
As mentioned above, yeast overgrowth is due to different factors, however, it is susceptible to a wide variety of anti-fungal agents. Malassezia folliculitis is usually treated with topical antifungals. Dandruff shampoos are considered a good alternative, since they contain anti-fungal ingredients, such as Ketoconazole, zinc pyrithione, or Selenium sulfide. However, one study shows that topical Ketoconazole is much less efficient in clearing lesions than oral Ketoconazole . indicating that using topical antifungals might not be a reliable method of treatment.
Is there a way to prevent it?
Even after successful treatment, reoccurrence is quite common, especially for people living in hot and humid climates. It is suggested to use topical agents as a maintenance and prophylactics tool to avoid flare-ups in Summer.
Pityrosporum folliculitis may persist for many years if misdiagnosed as acne. It might be beneficial to reconsider patients’ treatment if it is unresponsive to conventional acne medication. Depending on many factors recurrence of the disease is possible, however, if diagnosed properly, it responds to a wide variety of anti-fungal medication .
1. Pedrosa, A. F., Lisboa, C., & Rodrigues, A. G. (2014). Malassezia infections: A medical conundrum. In Journal of the American Academy of Dermatology (Vol. 71, Issue 1, pp. 170–176). Elsevier BV. https://doi.org/10.1016/j.jaad.2013.12.022
2. Ayers, K., Sweeney, S. M., & Wiss, K. (2005). Pityrosporum Folliculitis. In Archives of Pediatrics & Adolescent Medicine (Vol. 159, Issue 1, p. 64). American Medical Association (AMA). https://doi.org/10.1001/archpedi.159.1.64
3. Rubenstein RM, Malerich SA. Malassezia (pityrosporum) folliculitis. J Clin Aesthet Dermatol. 2014 Mar;7(3):37-41. PMID: 24688625; PMCID: PMC3970831.
4. Amanda Oakley, “Malassezia folliculitis” DermNetnz.org (1997), Updated by Dr Thomas Stewart, General Practitioner, Sydney, Australia, November 2017. Revised September 2020