Acne is the bane of many of us, especially in youth. But what if your acne persists later in life?

Do you have acne that continues to be a problem despite months or years of creams, treatments and ointments?

If that is the case for you then you may be suffering from fungal acne.

Fungal acne is an often misdiagnosed condition. Most people and even a lot of doctors can confuse it with the more common acne, acne vulgaris. But many wonder how to get rid of fungal acne even if they get the right diagnosis.

To know the difference and get the right treatment it helps to know what acne is in the first place.

Do I have fungal or regular acne?

‘Regular acne’ is a disease of the sebaceous glands i.e., where your natural skin oils come from. It causes your pores and hair follicles to become blocked more easily with dead skin, oils and general dirt from your environment. These blocked pores form white and blackheads, known as open or closed comedones respectively.[1]

Almost 90% of men and women will experience some form of common acne vulgaris throughout their life, with most cases starting in adolescence.

The blocked pores can form spots or pustules, which leads to residual scarring in some cases and can have a negative impact on self-image, especially with younger people. In many cases it is a specific bacteria, Propionibacterium acnes, which causes the spots to form.

Aside from simply adolescence, there are many other contributing factors to suffering from acne, including genetics, chocolate consumption, dairy consumption, fatty foods and environmental factors such as makeup and smoking.

So what is fungal acne?

The scientific term for fungal acne is pityrosporum folliculitis. The disease unfortunately looks and presents in a very similar fashion to acne vulgaris. 

Even in the scientific community it has another name confusingly, malassezia folliculitis, which is the newer term for the condition. Whichever of these terms are used, they mean the same thing:

Acne or pimples that are caused by a yeast infection, not bacteria.

Often treated with standard acne treatments and medications, this form can last for years, resistant to efforts to clear it.

The yeast can get into the same pores and follicles that acne vulgaris affects, making it easier for bacteria to get into the skin. This means that many people who suffer from fungal acne also have some element of regular acne at the same time.

If your immune system is reduced or impaired because of some other treatment or medical condition, then this gives the yeast a chance to grow, giving the spotty fungal appearance that many are trying to rid themselves of. Even using antibiotics for something like a lung infection can hamper your natural immune system enough to let the yeast cells multiply and produce acne spots.

Can any yeast cause fungal acne?

Don’t worry, baking bread and cakes with yeast or even having other fungal infections like candida or thrush will not put you at increased risk of fungal acne.

This is because the yeast is a specific type, malassezia, hence the alternate name given by the scientific community.

There are many types of malassezia with odd sounding names like furfur and globosa. Regardless of the type, they all have the same effect on your skin.

How can I tell it’s fungal acne?

The issue with detecting this type of skin problem is its similarity to other forms of acne. As it is not bacterial in nature, there is some variation in symptoms that can help tell things apart.

Sometimes the fungal acne will produce uniform lumps, i.e., all the bumps look the same. They can also be less red and very itchy when compared to regular acne.

Malassezia is connected to other skin conditions, such as folliculitis, pityriasis versicolor and seborrhoeic dermatitis. That is, it makes having these conditions more likely and they can often appear together.

Fungal acne causes

Fungal acne affects different types of people compared to acne vulgaris. Both men and women get regular acne, but women are more likely to suffer from it, especially if they use a lot of makeup. Men on the other hand, are more susceptible to the fungal variant. Those who live in hot climates are at even greater risk because the yeast thrives in the balmy weather.

Other risk factors you should be aware of include:

Greasy skin[2]

This is the key to fungal acne eruptions and the key to successful management of the condition. The fungal spores use our natural skin oils and any other oils we apply via creams to feed and grow.

If you suffer from a fungal infection then it is most likely to be found in the greasiest areas on your body. So if you are too over enthusiastic with moisturizing your face, for example. Not only will clogging your pores make you more susceptible to regular acne vulgaris, it will also feed any fungal spores on your skin and in your pores.

Different areas of your body will naturally be more oily depending on your individual makeup. So for you that might mean your forehead, chin or even back. Whichever is the most affected, that is where you will have to take the most care to ensure it is not an overly oily breeding ground for Malassezia fungi.

Heavy application of moisturizer, sunscreen or makeup[3]

Minimal moisturizer use is fine on very dry skin that needs hydration but try and avoid overuse. In particular, don’t rub moisturizer or other oil-based products into an area that is currently showing signs of fungal acne. The yeast spores will feed on the extra oil, only making the problem worse.

Excessive sweating[4]

Your body temperature and moisture are the perfect environment for many microbes, including yeast. While you don’t want to avoid going to the gym or getting away for a holiday in the sun, personal cleanliness is a must.

Don’t walk around in your gym clothes for longer than needed and regularly wash everything, especially when you are having an outbreak.

Recent antibiotic use[5]

This may be a bit confusing but antibiotics can hinder as well as help your general health. While we take antibiotics to fight bacteria that are making us feel unwell, the same antibiotics can also clear out healthy, good bacteria that live on our skin and in our gut.

In the absence of these helpful bacteria, we find that yeast cells can quickly multiply and start producing symptoms of a malassezia infection.

Recent steroid use[6]

Steroids aren’t just for shady gym use. They are needed for a wide range of lung, gut and skin concerns. If you use steroids, check with your doctor if the particular type you are taking promotes yeast growth. You may find switching to an alternative medication can calm down what seems to be an untamable skin problem.

Poor or weak immune system[7]

This includes those taking chemotherapy or have a chronic immune suppressor like HIV. Reduced response to any infection naturally means yeast cells are free to move around your skin and can infect hair follicles given the right conditions. In these cases careful management between your main physician and dermatologist is the wisest idea.

Remember that malassezia affects different areas than you might expect. Yes, outbreaks of fungal acne occur on the face, such as the forehead and chin, and also the back of the neck, chest and back of the arms. Wearing tight, non-breathable clothing makes spots on the body much more likely.

How can I get a proper diagnosis?

Although commonly missed as a diagnosis, all that is needed is a review from your family doctor or dermatologist.

They may want to take some minor skin scrapings to send to the lab. It is not a painful procedure and is very useful in getting a confirmed diagnosis quickly. If your dermatologist is used to seeing this type of infection, then he or she may recommend that no lab test is required and instead give a diagnosis based on appearance only.

How can I best treat fungal acne?

First things first, you should refer to the above risk factors and try to minimize them as much as possible. That might mean changing your diet to contain less fat and holding back on the moisturizer if you are overdoing it.

This is important because even with stronger treatment, without changing or reducing lifestyle factors there is always the risk of recurrence, i.e., the disease coming back.

When treating mild or minor conditions at home, it is always best to start with the least invasive treatment or the one with the least side effects.

A gentle fungal acne treatment

One safe but relatively unknown treatment option is to use a shampoo which contains sulfides in it. Yes you read that correctly, using shampoo on your skin. A number of anti-dandruff shampoos use sulphur containing compounds such as selenium sulfide, which help combat yeast cell growth. Just make sure you read the ingredients on the label to make sure the brand you pick does actually contain the sulfides you need. In terms of using the shampoo as a wash, just rub it into affected areas for a couple of minutes before rinsing well with water.

The best fungal acne treatment

The ‘gold standard’ treatment however is oral antifungal medication. Known under such names as fluconazole and itraconazole, they are by far the most effective way of treating an outbreak.[8]

There are some specialist shampoos and body washes available. These are great as they can treat from the outside-in while any tablets treat from within. A shampoo or body wash with Ketoconazole will be much more effective than a sulfide-based anti-dandruff shampoo.

These should be used daily until the obvious signs of infection clear. It can then be used a few times a month to keep recurring infections at bay.

To increase the effectiveness of any topical skin treatment, it can be useful to cleanse your skin to unclog the pores of dead skin and debris. This will allow deeper penetration and increased effectiveness of your medication.

Unfortunately, even with prompt treatment the acne is likely to return, even more so in hot and humid countries. That is where topical (on the skin) solutions like econazole may help in conjunction with tablets.

Does tea tree oil work for fungal acne?

In a word yes, but the answer is not so simple. Remember we mentioned that there are different types of Malassezia with odd names like Furfur?

Well for about two thirds of the Malassezia species that cause fungal acne using Tea tree oil is just as effective as antifungal medication like econazole and miconazole. For the remaining third however, the choice is clear:

Ketoconazole is the best antifungal treatment that effectively treats all types of Malassezia. So while Tea Tree Oil may be a good home recipe to try, keep in mind that it won’t be effective in around a third of cases.[9]

How long does treatment take?

This is the burning question for many people who suffer from fungal acne symptoms. Some find that even when they have been put on oral antifungal medication, the infection doesn’t clear up as fast as they had hoped. Poorly or untreated fungal acne can last for months or even years depending on the person, their lifestyle and climate they live in. 

This is due to the ability of the yeast cells to get deep into the hair follicles. Oral medication does penetrate further into the follicles than other topical treatments like shampoos but can use a bit of help from time to time.

But how can you help medication be more effective?

By using the very thing it is trying to treat, your skin and pores. Regular exercise, such as going for a run or getting stuck in at the gym will naturally create sweat, which has been shown to pull the active ingredients of the medication through the skin layers and into the follicles which need treatment. Just don’t sit around in those non-breathable clothes.

Conclusion: Preventing fungal acne

It may sound simple but slightly more stringent hygiene is usually your best bet at prevention, which in the case of fungal acne is definitely easier than cure.

This goes along with of course minimizing your exposure to overly hot and humid environments and as mentioned, keeping swimming and gym clothes washed well and only worn when necessary.

By maintaining a good, low-fat diet and using a natural cleanser you can keep oils and dirt from clogging your skin and trapping infective yeast cells. In the long run this will keep your face clear and prevent you from having to visit the dermatologist and from using aggressive fungal acne products.

References

1. Tan AU, Schlosser BJ, Paller AS. A review of diagnosis and treatment of acne in adult female patients. Int J Womens Dermatol. 2018;4(2):56-71.
2. Wolf R, Matz H, Orion E. Acne and diet. Clin Dermatol. 2004;22(5):387-93.
3. Grice EA, Dawson TL. Host-microbe interactions: Malassezia and human skin. Curr Opin Microbiol. 2017;40:81-87.
4. George RM, Sridharan R. Factors Aggravating or Precipitating Acne in Indian Adults: A Hospital-Based Study of 110 Cases. Indian J Dermatol. 2018;63(4):328-331.
5. Leyden JJ, Marples RR, Mills OH, Kligman AM. Gram-negative folliculitis–a complication of antibiotic therapy in acne vulgaris. Br J Dermatol. 1973;88(6):533-8.
6. Triana S, De cock H, Ohm RA, et al. Lipid Metabolic Versatility in spp. Yeasts Studied through Metabolic Modeling. Front Microbiol. 2017;8:1772.
7. Rosenthal D, LeBoit PE, Klumpp L, Berger TG. Human Immunodeficiency Virus-Associated Eosinophilic Folliculitis: A Unique Dermatosis Associated With Advanced Human Immunodeficiency Virus Infection. Arch Dermatol. 1991;127(2):206–209. doi:10.1001/archderm.1991.01680020074008
8. Youngchim S, Nosanchuk JD, Chongkae S, Vanittanokom N. Ketoconazole inhibits Malassezia furfur morphogenesis in vitro under filamentation optimized conditions. Arch Dermatol Res. 2017;309(1):47-53.
9. Hammer KA, Carson CF, Riley TV. In vitro activities of ketoconazole, econazole, miconazole, and Melaleuca alternifolia (tea tree) oil against Malassezia species. Antimicrob Agents Chemother. 2000;44(2):467-9.