20 July 2020
Have you heard of ‘fungal acne’ or malassezia folliculitis? Despite what its name suggests, ‘fungal acne’ is not acne at all. Acne vulgaris and pimples are associated with increased hormone changes, increased oiliness of the skin and bacterial overgrowth. Fungal acne, on the other hand, is caused by a fungus, leading to acne- like lesions.
Here’s what you need to know about fungal acne, a type of folliculitis is NOT acne vulgaris.
Fungal acne is caused by a type of yeast called malassezia, so fungal acne is also known as malassezia folliculitis. The older name for malassezia is pityrosporum, so you might come across older articles that refer to fungal acne as pityrosporum folliculitis. The raised bumps caused by malassezia folliculitis look similar to papules and pustules in acne vuglaris. However, this acneiform lesions in malassezia folliculitis are quite different from the pimples in vulgaris.
Under normal circumstances, yeast and bacteria are present on our skin. Before you cringe, some of these microorganisms have a protective function to defend the skin against harmful pathogens. This balance of bad bacteria and good bacteria in the normal skin flora is crucial for skin health. I’ve shared about the balance between good and bad bacteria on our skin in this blogpost Probiotics in Skincare and Supplements: Do They Work? If this balance is disrupted, an overgrowth of Malassezia yeast can cause fungal acne.
Malassezia yeast is found in the sebaceous glands of the skin, where they thrive on sebum; similar to Cutibacterium acnes (formerly known as Propionibacterium acnes), the bacteria that causes acne vulgaris.
An overgrowth of Malassezia yeast can occur with medications such as antibiotics and steroids. These medications disrupt the normal flora and encourage growth of Malassezia furfur yeast.
Sweating and humidity are also associated with malassezia folliculitis. Hence, wearing tight, unbreathable clothing can contribute to fungal breakouts. If you wear workout clothes that are sweaty, please change and wash them before using them again.
Fungal acne is also linked to increased sebaceous gland activity i.e. oiliness of the skin. This is also one of the predisposing causes of acne vulgaris; so some patients may have both malassezia folliculitis and acne vulgaris.
Malassezia folliculitis occurs more commonly on the body parts covered by clothing such as the upper back, chest and shoulders. Less commonly, fungal acne occurs on the face and scalp.
The appearance of fungal acneiform lesions is that of uniform red papules and pustules. Comedones are usually absent, unlike acne vulgaris. Fungal acneiform lesions are also itchy, unlike acne vulgaris. For a look at the 4 different types of acne and how pimples can be treated, please read this blogpost Acne: Types, Causes, Treatments and Prevention.
Fungal acne and acne vulgaris have some similarities. Both types of acne can also occur in the same patient, so fungal acne may be misdiagnosed because it is less common than acne vulgaris.
Here are the differences between acne vulgaris vs malassezia folliculitis:
1. Different culprits
Fungal acne/ malassezia folliculitis is caused by an overgrowth of Malassezia yeast. Acne vulgaris is caused by the bacteria Cutibacterium acnes. Hormone changes, increase in oiliness of the skin and follicular plugging also contribute to acne vulgaris.
2. Different locations on the face and body
The pimples in acne vulgaris and fungal acne can occur in the T zone of the face. The T-zone of the face tends to be more oily in most people. Both the Malassezia yeast and Cutibacterium acnes feed off the sebum produced by sebaceous glands.
In hormonal acne, the pimples tend to occur in the lower face (jawline, neck and around the mouth). Fungal acne, on the other hand, occurs more commonly over the body parts covered by occlusive clothing. However, malassezia folliculitis can also occur on the face, such as the forehead. As mentioned before, sweating + restrictive clothing are a combination for fungal acne.
The acneiform lesions in fungal acne/ malassezia folliculitis tend to be itchy, especially after sweating and increase in body temperature (e.g. after exercising). Itching is not a common feature in acne vulgaris.
In malassezia folliculitis, the pimples have a similar appearance- uniform looking papules and pustules. The size of pimples are also smaller. In acne vulgaris, a combination of pimple types are usually present- comedones (clogges pores or blackheads and whiteheads); papules and pustules can be seen. Papules and pustules are preceded by comedones. The papules and pustules can also vary in size; some can be 2-4mm in size.
Malassezia folliculitis is a clinical diagnosis. Fungal scrappings may be required sometimes.
Simple lifestyle changes like changing out of sweaty and tight exercise clothing and keeping skin clean and dry are important, especially to prevent recurrences. You can wear looser exercise outfits with materials that dry faster. Try to shower after you work out; this will help too.
Mild cases of malassezia folliculitis can respond to topical cleansers. Choose anti-fungal ingredients such as zinc pyrithion and selenium sulphide in your face/ body washes. Some anti-fungal medications like ketoconazole creams can be bought over the counter. Give these washes enough time (about 5 minutes) to sit on your skin before rinsing off. These washes can be drying and irritating, especially if you have sensitive skin. Moisturising your skin with lightweight products like lotions and gels are a better option than thicker creams.
Malassezia yeast feed off sebum in the sebaceous glands, so anti-sebum active ingredients can also reduce the recurrence of fungal acne. Ingredients like BHA (salicylic acids) and retinoids remove sebum or reduce sebum formation. Although these ingredients can be found in over the counter skincare products; but prescription strength retinoids and acids are more effective.
If you have severe or persistent malassezia folliculitis, you’ll need professional help from your doctor.
The mainstay of treatment for malassezia folliculitisis with anti-fungal medications like ketoconazole and fluconazole. The Malassezia fungi lie deep within the pilosebaceous unit so oral anti-fungal medications are usually needed. Topical washes and creams have a more difficult time reaching deep into the pilosebaceous unit but are still important for maintenance and prevention of recurrence.
Fungal acne looks like acne but is not acne at all. Both acne vulgaris and malassezia folliculitis have some similarities and can occur in the same patient, so misdiagnosis can occur. If in doubt, seek professional help from your doctor..