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Fungal Acne: why you shouldn’t treat it like “acne” (Infographic)

If you’ve been wondering whether you have fungal acne, you’re in luck. This post and infographic will tell you everything you need to know about fungal acne and how to get rid of it. The article (and the infographic below) is based on the latest research in the field of pityrosporum folliculitis.

What is fungal acne

Fungal acne or pityrosporum folliculitis isn’t really acne, but rather an acne-like skin disorder resulting in small and itchy bumps on the skin. It’s a common misconception to think that fungal acne is just another type of acne. But since the main culprit of pityrosporum folliculitis is a yeast instead of a bacteria, it doesn’t fall under the umbrella of acne (vulgaris)[1]ABDEL-RAZEK, M., FADALY, G., AHDEL-RAHEIM, M., & AL-MORSY, F. (1995). Pityrosporum (Malassezia) folliculitis in Saudi Arabia-diagnosis and therapeutic trials. Clinical and Experimental … Continue reading.

By extension this means that most conventional acne treatments such as antibiotics will not only be ineffective but can actually worsen the problem.

The fungus that causes “fungal acne” is called malassezia and it’s a real pain in the bum. Malassezia is present on the skin of 92% of all people but only seems to trigger breakouts in people who are sensitive to it [2]Gaitanis, G., Magiatis, P., Hantschke, M., Bassukas, I. D., & Velegraki, A. (2012). The Malassezia Genus in Skin and Systemic Diseases. Clinical Microbiology Reviews, 25(1), … Continue reading. The fungus thrives on the fatty acids and oils on the skin which means it can grow very rapidly by absorbing these “nutrients”.

There are about 14 different malassezia species which can all mess with your skin in unique ways. These 14 different malassezia species can cause a host of different problems beside fungal acne including: eczema, dandruff, seborrheic dermatitis, and the list goes on… Note that this doesn’t mean that you have to use 14 different treatments to get rid of fungal acne (or any of the other conditions) but we’ll get to that in a bit.

What causes fungal acne symptoms?

You might be wondering why pityrosporum folliculitis pops up in the first place.. Well there are a bunch of different things that can actually cause fungal acne.

For example research shows that there is a correlation between fungal acne and people with a nutritional disorder, a compromised immune system, neurotransmitter abnormalities, diabetes or bone marrow transplant recipients [3]Farris, P. K., & Murina, A. (2013). Malassezia Folliculitis. Acneiform Eruptions in Dermatology, 59–65. doi:10.1007/978-1-4614-8344-1_9. This means that if your body is compromised, it can allow the malassezia to thrive and cause problems.

Other causes for fungal acne are undesirable external conditions such as humid weather and wearing restricting clothing. Humid weather causes sweating and in combination with tight clothing this results in a skin environment that is perfect for yeast growth.

Lastly, fungal acne can form is through the use of antibiotics for extended periods of time. Antibiotics can negatively impact your body’s microbiome which in turn causes malassezia to proliferate. This is a very important finding since antibiotics have often been prescribed to patients who suffer from fungal acne but have been misdiagnosed as having acne vulgaris. Using antibiotics is usually not the right call, even when you’re suffering from acne vulgaris but in this instance, it can actually do significantly more harm[4]Weary, P. E. (1969). Acneform Eruption Resulting From Antibiotic Administration. Archives of Dermatology, 100(2), 179. doi:10.1001/archderm.1969.01610260055009.

The infographic below shows you why you shouldn’t treat fungal acne like “regular acne”:

What is fungal acne?

How to know if you have fungal acne

If you’re not really sure whether you have acne vulgaris or fungal acne, I can’t blame you. The fact that fungal acne has been misdiagnosed so frequently tells us it’s a tricky condition, to say the least. However, if you know what you’re looking for it’s quite easy to discover whether you have fungal acne or not:

  1. You have small acne-like bumps on your back, chest, or shoulders. As a ground rule, if you have small bumps on your chest, shoulder, and back, chances are you’re suffering from fungal acne. The combination of sweating and restricting clothing can cause these areas to flare up. This doesn’t mean that fungal acne doesn’t appear on the face, but significantly less frequently.
  2. You break out from nearly anything you put on your skin. Since Malassezia feeds of oils, chances are most skin products will break you out.
  3. You break out more in the summer. Most people that suffer from acne vulgaris claim their skin clears up during the summer. However, if you suffer from fungal acne, the opposite happens. The humid weather allows Malassezia to thrive and causes more breakouts.
  4. You don’t see a major infleunce of diet on your breakouts. If you have acne vulgaris you’ll definitely see huge differences in your skin after a snack binge. Eating a big tub of ice cream can wreak havoc on your skin. And eventhough there’s a correlation between carbs and yeast growth, in general the severity of fungal acne is less corolated with diet.
  5. While using a blacklight, you’re pimples light up blue-white-yellow. Since bacterial acne lights up “orange-redish”, you know you have fungal acne if the color of the pimple is more “blue-white-yellowish”. Doctors can do something called wood lamp examinations which are basically blacklight examinations to look at the color of the lesion[5]Ponka, D., & Baddar, F. (2012). Wood lamp examination. Canadian family physician Medecin de famille canadien58(9), 976..

What does fungal acne look like?

The easiest way to show you what fungal acne looks like would be to share some photos with you. So here are some fungal acne photos. For those of you who’ve already seen too many horrific pimple popper video’s (I’ve been there) I’ll try to explain it in words.

Fungal acne looks a lot less intense than, for example, cystic acne. We’re talking about cystic acne when there are huge inflammatory lesions on the skin with big yellow pouches of puss. That doesn’t sound too appetizing, does it? Fungal acne on the other hand is characterized by small red bumps on the face, neck, shoulders, chest and back. Moreover, the bumps that result from a Malazzesia outbreak don’t usually come to a head. This means you won’t be able to extract the puss as you see in those popper videos…

If you were to compare the fungal bumps to acne vulgaris, you could say they’re similar to non-inflammatory whiteheads only more reddish.

Fungal acne treatment

All right, so by now you already know quite a bit about fungal acne. It’s time we look at ways of getting rid of it so that you can once again enjoy beautiful and flawless skin.

We’ll take a multi step approach to getting rid of fungal acne. First we’re going to look at things you want to avoid, so as to not make the situation worse. And then we’re going to look at both internal and external ways of taking down Malassezia.

What to avoid

Like we already said, malassezia feeds of fatty acids and (skin) oils. More specifically they feed on fatty acids with a carbon chain length between 12-24[6]Wilde, P. F., & Stewart, P. S. (1968). A study of the fatty acid metabolism of the yeast Pityrosporum ovale. Biochemical Journal108(2), 225-231. If you don’t know what that means don’t worry. What it boils down to is that most of the skin products that are on the market today are a “no-go”. They contain fatty acids or oils that Malassezia feeds on.

Malassezia has enzymes that turns the oils from these skin products into free fatty acids to feed off of. Below you’ll find a list of ingredients that you need to look out for in a skincare product[7]Porro, M. N., Passi, S., Caprilli, F., Nazzaro, P., & Morpurgo, G. (1976). Growth requirements and lipid metabolism of Pityrosporum orbiculare. Journal of Investigative … Continue reading:

  • Undecylenic Acid (C11)
  • Lauric / Dodecanoic (C12)
  • Tridecylic (C13)
  • Myristic / Tetradecanoic (C14)
  • Pentadecanoic (C15)
  • Palmitic / Hexadecanoic (C16)
  • Palmitoleic / Hexadecenoic (C16:1)
  • Margaric (C17)
  • Stearic / Octadecanoic (C18)
  • Oleic / Octadecenoic (C18:1)
  • Linoleic (C18:2)
  • α-Linolenic (C18:3)
  • Nonadecylic (C19)
  • Arachidic / Eicosanoic (C20)
  • Heneicosylic (C21)
  • Behenic / Docosanoic (C22)
  • Tricosylic (C23)
  • Lignoceric / Tetracosanoic (C24)

Especially oleic acid can be detrimental to a clear skin since it’s used to grow malassezia quickly in research studies[8]Nelson, S. C., Yau, Y. C., Richardson, S. E., & Matlow, A. G. (1995). Improved detection of Malassezia species in lipid-supplemented Peds Plus blood culture bottles. Journal of clinical … Continue reading. Besides fatty acids, it turns out things such as esters, fatty alcohols and polysorbates can also aggravate fungal acne[9]c., f. (2017). The Fungal Acne Treatment Bible (2021): Cure Malassezia With Science!. Retrieved 24 May 2021, from simpleskincarescience.

Too avoid making things confusing it might be better to give you a list of “fungal acne products” that most likely won’t break you out:

Oils

  • MCT oil
  • Caprylic acid oil
  • Mineral oil

Chemical exfoliants

  • Tretinoin
  • Benzoyl peroxide
  • Salicylic acid
  • Paula’s choice 8% AHA
  • 10% sulfur ointment
  • Glycolic acid cleanser

Moisturizers

  • Bioderma hydrabio gel cream
  • Cerave cream
  • Curel intensive moisture care cream
  • La Roche Posay Toleraine oil free moisturizer

Sunscreens

  • Colorscience sunforgettable mineral spf 50
  • La Rosche Posay Anthelios AOX SPF 50

Oral fungal acne treatment

So now that you know what things to avoid, let’s get down to the brass tacks of beating Malassezia and getting clear skin. While it’s a good idea to avoid products that can feed the Malassezia, it’s even more important to incorporate products that will actually combat the root cause. These products are called antifungals.

Now there are a lot of different antifungals to choose from, but for the sake of simplicity we’ll only cover the most effective one here.

Up first is Ketoconazole. This anti-fungal has been researched extensively and has proven to be very effective against every species of Malassezia[10]Gupta, A. K., Kohli, Y., Li, A., Faergemann, J., & Summerbell, R. C. (2000). In vitro susceptibility of the seven Malassezia species to ketoconazole, voriconazole, itraconazole and … Continue reading. According to a study by Abdel-Razek et al. using ketoconazole 200mg orally in combination with a topical 2% ketoconazole shampoo resulted in 100% clearing in 1 month[11]ABDEL-RAZEK, M., FADALY, G., AHDEL-RAHEIM, M., & AL-MORSY, F. (1995). Pityrosporum (Malassezia) folliculitis in Saudi Arabia-diagnosis and therapeutic trials. Clinical and Experimental … Continue reading. It’s important to note that the combination of an oral and topical ketoconazole treatment was more effective than either alone.

The second option is Itraconazole. It’s very similar to ketoconazole in effectiveness, but since off-label ketoconazole has been linked to an increased death risk, going for the itraconazole is probably the safer bet. Moreover, Itraconazole has been proven to be even more effective in some instances[12]Tricot, G., Joosten, E., Boogaerts, M. A., Vande Pitte, J., & Cauwenbergh, G. (1987). Ketoconazole vs. itraconazole for antifungal prophylaxis in patients with severe granulocytopenia: … Continue reading.

Taking this into consideration I suggest going with Itraconazole.

External fungal acne treatment

Like the study by Abdel-Razek above suggested, combining topical and oral fungal acne treatments leads to significantly better results. And it turns out there is a very effective and affordable way of treating fungal acne topically: dandruff shampoo. Now you might be wondering what dandruff shampoo has got to do with fungal acne. Well, it turns out most dandruff shampoos have ketoconazole in them. Using a dandruff shampoo (with ketoconazole) on the affected area twice a week for 3-5 minutes until the lesions disappears is advised.

Another effective topical fungal acne treatment is the use of “keratolytic agents”. These are just exfoliants that inhibit the growth of malassezia. Now since continued use of antifungals can lead to antifungal resistance it’s wise to use these exfoliants to keep the malassezia in check. What I mean by this is that you can use the oral and topical antifungals until the fungal acne is completely gone. And after that you can just use an exfoliant once or twice a week to make sure everything stays nice and quiet.

Frequently asked questions

Is there a fungal acne diet

Like I mentioned above, there seems to be less of a correlation between fungal acne and diet. Fungi and yeast do feed on carbohydrates so it’s definitely a good idea to stay away from sugar and carbohydrate rich foods. But anecdotal evidence suggest that diet doesn’t have as much of an impact in fungal acne when compared to acne vulgaris for example.

Is fungal acne the same as yeast acne

Fungal acne and yeast acne are basically the same thing. The fungus Malassezia causes inflammation in the hair follicle which leads to acne-like break outs.

Can I use ketoconazole for fungal acne?

You can definitely use ketoconazole, both topically and orally. Although my recommendation would be to use itraconazole as an oral treatment and ketoconazole as a topical treatment. This leads me right into the next question.

What is the best fungal acne shampoo

The best fungal acne shampoo is one with 1-2% ketoconazole. The head and shoulders shampoo is going to be a safe bet.

References

References
1ABDEL-RAZEK, M., FADALY, G., AHDEL-RAHEIM, M., & AL-MORSY, F. (1995). Pityrosporum (Malassezia) folliculitis in Saudi Arabia-diagnosis and therapeutic trials. Clinical and Experimental Dermatology, 20(5), 406–409. doi:10.1111/j.1365-2230.1995.tb01358.x 
2Gaitanis, G., Magiatis, P., Hantschke, M., Bassukas, I. D., & Velegraki, A. (2012). The Malassezia Genus in Skin and Systemic Diseases. Clinical Microbiology Reviews, 25(1), 106–141. doi:10.1128/cmr.00021-11
3Farris, P. K., & Murina, A. (2013). Malassezia Folliculitis. Acneiform Eruptions in Dermatology, 59–65. doi:10.1007/978-1-4614-8344-1_9
4Weary, P. E. (1969). Acneform Eruption Resulting From Antibiotic Administration. Archives of Dermatology, 100(2), 179. doi:10.1001/archderm.1969.01610260055009
5Ponka, D., & Baddar, F. (2012). Wood lamp examination. Canadian family physician Medecin de famille canadien58(9), 976.
6Wilde, P. F., & Stewart, P. S. (1968). A study of the fatty acid metabolism of the yeast Pityrosporum ovale. Biochemical Journal108(2), 225-231
7Porro, M. N., Passi, S., Caprilli, F., Nazzaro, P., & Morpurgo, G. (1976). Growth requirements and lipid metabolism of Pityrosporum orbiculare. Journal of Investigative Dermatology66(3), 178-182.
8Nelson, S. C., Yau, Y. C., Richardson, S. E., & Matlow, A. G. (1995). Improved detection of Malassezia species in lipid-supplemented Peds Plus blood culture bottles. Journal of clinical microbiology33(4), 1005-1007.
9c., f. (2017). The Fungal Acne Treatment Bible (2021): Cure Malassezia With Science!. Retrieved 24 May 2021, from simpleskincarescience
10Gupta, A. K., Kohli, Y., Li, A., Faergemann, J., & Summerbell, R. C. (2000). In vitro susceptibility of the seven Malassezia species to ketoconazole, voriconazole, itraconazole and terbinafine. The British journal of dermatology142(4), 758–765.
11ABDEL-RAZEK, M., FADALY, G., AHDEL-RAHEIM, M., & AL-MORSY, F. (1995). Pityrosporum (Malassezia) folliculitis in Saudi Arabia-diagnosis and therapeutic trials. Clinical and Experimental Dermatology, 20(5), 406–409.
12Tricot, G., Joosten, E., Boogaerts, M. A., Vande Pitte, J., & Cauwenbergh, G. (1987). Ketoconazole vs. itraconazole for antifungal prophylaxis in patients with severe granulocytopenia: preliminary results of two nonrandomized studies. Reviews of infectious diseases9 Suppl 1, S94–S99.

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