What Is Fungal Acne? How to Recognise and Treat It

Fungal acne is one of the more commonly overlooked skin conditions. The bumps look similar enough to regular acne that most people use standard acne treatments, which usually don’t work. This can lead to the condition going unrecognised for months, or even years.

Fungal acne is driven by a yeast that lives on everyone’s skin, multiplying inside the hair follicle. That is why it responds to antifungal treatment rather than to products aimed at acne. Once it has been identified, fungal acne is usually straightforward to clear.

Recognising fungal acne is the part worth getting help with. Small, itchy bumps that haven’t responded to acne treatment, with no blackheads or whiteheads among them, are worth showing a doctor. In this article, we’ll cover everything you need to know about fungal acne, including what causes it, why acne treatments don’t clear it, and how to get treatment in Canada.

An Overview of Fungal Acne (Malassezia Folliculitis)

Fungal acne is an infection of the hair follicle caused by a type of yeast known as Malassezia. This group of yeasts makes up the great majority of the fungi found on healthy human skin, and usually sits most densely where the skin is oiliest: the scalp, face, chest and upper back. Most of the time Malassezia does not cause any problems. However, it can cause fungal acne when the yeast multiplies inside the hair follicle and the follicle inflames in response.

When researchers compared affected and unaffected skin on the same patients with fungal acne, they found the same Malassezia species in similar numbers. This suggests fungal acne is an overgrowth of your own resident yeast. Doctors usually call the condition Malassezia folliculitis, or by its older name, Pityrosporum folliculitis (fungal folliculitis is another name that means the same thing). “Fungal acne” is the term that took hold online, even if the process underneath the condition has little in common with standard acne.

Diagnosing fungal acne is usually straightforward. A doctor can often recognise it from the pattern of the bumps and where they occur. Where there is any doubt, a small scraping of skin examined under a microscope will show the yeast. The bumps from fungal acne usually settle over a few weeks of treatment with a topical or oral antifungal, though recurrence is common, so prevention is part of the plan.

What Does Fungal Acne Look Like?

How to identify fungal acne comes down to a handful of common features, and fungal acne symptoms are fairly distinctive once you know what to look for:

• Small, uniform bumps. Papules and pustules roughly one to two millimetres across, all much the same size and shape as one another, appearing in crops rather than one at a time.
• No blackheads or whiteheads. Fungal acne is an infection inside the follicle, so the plugged pores that produce comedones don’t form.
• Itch (more often than not). Itching is the symptom people report most, occurring in roughly seven of every ten patients across the published studies. However, many people notice no itch at all.

On the face, fungal acne tends to appear across the forehead and hairline and along the jawline. On the body, the upper back, chest and shoulders are the usual sites. Those are the areas where skin is oiliest and where sweat and clothing hold heat against it. 

In one study of 49 patients with fungal acne, the face was involved most often (57%), followed by the back (53%), the arms (39%) and the chest (37%), and most people had more than one area affected.

Fungal Acne vs Regular Acne: How to Tell Them Apart

The underlying causes of fungal acne and regular acne are different. 

Regular acne begins when a hair follicle plugs with keratin and oil, then becomes inflamed by Cutibacterium acnes bacteria, which is why regular acne tends to produce blackheads and whiteheads alongside inflamed spots. Fungal acne doesn’t produce blackheads or whiteheads because the trigger is a yeast multiplying inside the follicle, rather than a blocked pore. 

In practice, four things separate fungal acne from regular acne:

• Blackheads and whiteheads. Present in regular acne, absent in fungal acne. This is the most reliable single difference.

• Uniformity. Fungal acne bumps are all much the same size. Regular acne tends to show a mix of sizes and types at once.

• Itch. Common in fungal acne, unusual in regular acne.
• Treatment. Fungal acne doesn’t respond to most regular acne treatments, and can carry on for years while standard acne medication is tried.

Fungal acne and regular acne often occur together. In one review of 110 confirmed cases of fungal acne, only three patients had never had regular acne. 

A crop of small itchy bumps that appears or worsens while you are being treated for acne is the classic picture, and it usually calls for both conditions to be treated rather than a switch from one treatment to the other.

Fungal Acne vs Closed Comedones

Closed comedones, the small skin-coloured bumps often called whiteheads, are often confused with fungal acne because both produce a scattering of little bumps without obvious redness. The difference is that a closed comedone is a plug of keratin rather than an infection — it usually doesn’t itch, isn’t pustular, and won’t respond to antifungal treatment.

What Causes Fungal Acne

Malassezia yeast is already living on your skin, so fungal acne begins with something tipping the balance in its favour. A few things can cause this:

• Heat, humidity and sweat. Warm, damp skin can promote growth of the yeast that causes fungal acne.
• Occlusion (covering skin so it can’t dry out). Tight or non-breathable clothing, sports equipment and heavy, greasy skincare all hold moisture and oil against the skin.
• Antibiotics (including the ones prescribed for acne). In some fungal acne studies, more than three-quarters of patients had recently taken antibiotics for what was assumed to be acne. Why antibiotics have this effect is not settled. The usual explanation is that they reduce numbers of the bacteria that normally compete with Malassezia, though that model has not been proven.
• A weakened immune system. Fungal acne is more common in people who are immunosuppressed, including after an organ transplant, and in poorly controlled diabetes.

Fungal acne is not contagious. The yeast behind it is already living on everyone’s skin, so there is nothing to catch or pass on.

Why Standard Acne Treatments Don’t Clear Fungal Acne

Regular acne treatments are built for a bacterial, oil-driven process, and most have little effect on a yeast growing inside the hair follicle. Retinoids such as tretinoin and adapalene, and azelaic acid are generally ineffective against Malassezia itself.

Benzoyl peroxide is the exception worth knowing about. In laboratory testing, it killed several Malassezia species within an hour. No clinical trial has shown benzoyl peroxide clearing fungal acne on its own, so the ingredient sits better alongside antifungal treatment than in place of it.

Salicylic acid comes up regularly in online advice about fungal acne, but the evidence behind it is thin. Salicylic acid is a keratolytic, which means it loosens the outer layer of skin, and there is no good evidence of direct activity against the yeast. A trial of a high-strength salicylic acid preparation is underway, so the picture may change in the future.

Antibiotics are the one part of the acne kit that can make fungal acne worse rather than simply failing to help. The thought is that antibiotics upset the balance of bacteria on the skin, which promotes overgrowth of Malassezia. This is why it’s worth speaking to a doctor if your skin gets worse during a course of acne antibiotics.

How Fungal Acne Is Treated

How to treat fungal acne and which antifungal to use depends on how much skin is involved and how the condition has behaved before. The main choice is between a topical antifungal treatment or tablets, which are explained below.

Topical Antifungal Treatments (Applied to the Skin)

Most fungal acne is treated using a topical antifungal product containing ketoconazole, ciclopirox, selenium sulfide or zinc pyrithione. Creams are applied to the affected area and left on. Medicated shampoos and washes are lathered onto the affected skin, left for a few minutes, then rinsed off (which makes them easier to use over larger areas like the chest and back). 

Topical antifungal treatment usually works over about two to four weeks, which is slower than tablets. In Canada, the fungal acne cream most often prescribed is ketoconazole cream.

Antifungal Tablets

Tablets may be used when fungal acne is widespread, hasn’t settled with skin treatment, or keeps returning (also for people whose immune systems are suppressed). Itraconazole and fluconazole are the two antifungal tablets usually prescribed. 

In the only small randomised trial of the treatment, about 85% of patients were healed or much improved after a week of itraconazole tablets. Both itraconazole and fluconazole have side effects and risks worth knowing about, which a doctor can discuss with you.

Why Fungal Acne Often Comes Back (and What Keeps It Away)

A course of antifungal treatment usually takes two to four weeks to show a clear improvement in fungal acne. If the rash hasn’t shifted in that time, you should go back to the doctor, because it may mean the diagnosis needs revisiting or the treatment needs changing.

Clearing a fungal acne outbreak is only the first half of treatment. Because outbreaks often reoccur, an antifungal used less often (once or twice a week rather than daily) is usually the best method of prevention. How long that needs to continue depends on how regular your outbreaks are.

Skincare and “Fungal Acne Safe” Products

It’s best to keep heavy, oil-based products off the affected skin while you are treating fungal acne. Showering promptly after sweating and changing out of damp or tight-fitting clothing can also help.

Malassezia cannot make its own fatty acids and takes them from the skin instead. Therefore,  skincare products built on certain oils may make outbreaks worse. “Fungal acne safe” products are built around avoiding these oils. However, they generally have not been clinically tested, and no study shows that changing skincare on its own clears fungal acne.

Home Remedies for Fungal Acne

Fungal acne treatment at home is a common question, with a few home remedies regularly coming up. Tea tree oil has some laboratory activity against the yeast that causes outbreaks, but has never been tested on fungal acne. Apple cider vinegar has no evidence behind it, and often causes skin irritation. Overall, home remedies are not a substitute for the standard medical fungal acne treatments.

Fungal Acne Treatment in Canada

Fungal acne can be assessed and treated in Canada via an in-person or telehealth doctor’s appointment. A doctor can look at the rash, work out whether Malassezia might be behind it, and provide a prescription if appropriate.

If you are in British Columbia, an appointment with an online Walk In doctor is covered by MSP. If your skin hasn’t responded to standard acne treatment, seeing a doctor is a straightforward way to find out whether fungal acne is what you are dealing with.

Frequently Asked Questions About Fungal Acne

Is fungal acne contagious?

Fungal acne is not contagious. The yeast behind it lives on everyone’s skin already, so there is nothing to pass on. Sharing a towel or a gym bench won’t give someone fungal acne, and there is no need to keep away from anyone while you are being treated.

Is fungal acne itchy?

Itching is the most commonly reported symptom of fungal acne, though not everyone experiences it. A significant minority notice no itch at all, so fungal acne that doesn’t itch is still fungal acne.

Does fungal acne go away on its own?

Sometimes fungal acne settles when whatever triggered it goes away, such as the end of a course of antibiotics or a spell of hot weather. More often, it persists for months or years, particularly when it is being treated as regular acne. In one series of 26 patients, most had been treated unsuccessfully for acne for months to years before fungal acne was identified.

How do you get rid of fungal acne?

How to get rid of fungal acne depends on how much skin is involved. Most cases clear with an antifungal applied to the skin over two to four weeks, and tablets are used where the rash is widespread or keeps returning. Because it commonly comes back, a doctor will usually plan for that too.

What gets mistaken for fungal acne?

Regular acne is the most common thing that gets mistaken for fungal acne, followed by closed comedones. Bacterial folliculitis, keratosis pilaris, and perioral dermatitis can look similar too. Several of these can also occur at the same time as fungal acne, which is part of why it tends to be identified late.

Getting Fungal Acne Under Control

Fungal acne is a yeast infection of the hair follicle, so it responds to antifungals rather than to the acne products most people try first. Most cases settle within a few weeks of identifying the problem and starting the right treatment. Because fungal acne tends to return, preventing future outbreaks is usually part of the treatment plan.

If your skin hasn’t shifted after weeks of standard acne treatment, or the bumps are itchy and all much the same size with no blackheads or whiteheads, that is usually a sign to get a doctor’s opinion. A doctor can confirm whether Malassezia is behind your condition and match the treatment to how widespread it is, whether that’s an antifungal cream or a short course of tablets.

Speak to a Doctor Online About Fungal Acne