Fungal Acne: A misnomer. Medically it’s called Pityrosporum folliculitis

Acne is such a common condition that to an untrained eye, all red bumps (papules/pustules) must be acne.

There are other dermatological disorders that present like acne but are not acne.

Pityrosporum folliculitis or Malassezia folliculitis (Fungal acne in layman terms, but fungal acne is not a medical diagnosis since it’s not acne or form of acne) is one of the most common skin condition mistaken for acne. It is caused by increase colonisation (multiplication) of a yeast called Malassezia species which is normally present as part of the normal flora in our skin. (yes! our skin has a world of micro organisms living in it 😉 )

It is the inflammation caused by such an increase colonisation that causes the symptoms.

So what causes this increase colonisation by this yeast?

  • Malassezia thrives in the oily environment produced by the sebaceous glands. Adolescents (10-19 years) have an increase sebaceous glands activity due to the hormonal fluctuations. Therefore this condition is commonly seen in adolescents.
  • Excessive sweating is also a risk factor, and people living in hot humid areas are more predisposed.
  • Individuals on topical or oral antibiotic, as this can suppress the growth of the normal bacteria in the skin giving way for this yeast to multiply unchecked.
  • Use of steroids or other immunosuppressant agents.
  • Diabetic patients may also experience such eruptions.
  • Genetic predisposition also plays a role. As mentioned earlier everyone has this yeast in their skin, but only some people are able to mount an inflammatory response to it causing the symptoms while others do not.

How can you differentiate it from acne ?

Firstly by the looks of the lesion, fungal acne presents with monomorphic (uniform looking) papules (red raised bumps) or pustules (pus filled bumps). There will not be any comedones (such as white heads or black heads) unless a patient also has concurrent acne.

Secondly by examining the site of involvement, face (forhead), back, upper arms, chest and back are involved in fungal acne. One wouldn’t normally see acne vulgaris involving the upper arms, neck.

Thirdly, fungal acne tends to be itchy while acne is not. Do you ever remember your pimple itching unless you’ve picked on it and a scab has formed?

Fourthly, history of acne not responding to anti acne treatment despite strict compliance or acne which had responded to treatment and suddenly flares up even while on the same treatment.

Fifthy, individuals with fungal acne may also have dandruff or tinea versicolor.

Do you need to see a dermatologist for such a condition?

Its always better to get an expert opinion before you self treat any skin condition.

Though the above points can help distinguish between acne and fungal acne, it may not be as clear cut in most cases, especially when one also has co existing acne. A variant of acne called truncal acne vulgaris can also present with similar eruptions on the back and chest.

Another dermatological condition called acneiform eruption which presents as eruption of skin lesions similar to acne caused by certain medications, mechanical friction, certain compounds used in textile dyes, insecticides, pesticides, detergents or soaps (halogenated aromatic hydrocarbon) presents similar to acne, and is sometimes difficult to differentiate it from fungal acne.

This is where a dermatologist’s opinion is important, so that certain questions can be asked, and if necessary certain tests performed (such as Wood lamp examination or KOH mount which can help in the diagnosis of fungal acne) for the correct diagnosis and management of the condition.

How to treat it?

As it is seen that the organism causing fungal acne (i.e Malassezia sp) can multiply more in hot and humid areas and summers are the season for most flare ups due to the increase ambient temperature and sweating, measures to reduce these factors can help reduce the symptoms

  • Have frequent cold showers in the summers
  • Change clothing such as gym wear, uniforms as soon as possible
  • Opt for loose fitting clothing
  • Avoid tight fitting attire
  • Seek the comfort of an air conditioned room

Products to use :

Use an anti-fungal shampoo (such as 2% ketoconazole or selenium sulfide or zinc pyrithione), look out for these ingredients in your anti dandruff shampoos. (List of few of such shampoos on previous post)

2% Ketoconazole + zinc pyrithione
Zinc pyrithione
Zinc pyrithione

Massage the shampoos to the affected areas and leave it for 5-10 mins and wash off. This can be done twice weekly for at least 2-4 weeks depending on your response.

If the above fails, your dermatologists may add topical anti-fungal creams which are to be applied once-twice daily over the lesions.

Topical creams that helps to unclog the blocked sebaceous glands such as salicycic acid is another adjunctive treatment option in addition to the above.

Systemic anti-fungals (oral tablets/capsules) may be required in some cases.

Remember that the condition may recur, especially in summers.

Applying the anti-fungal shampoos during the summer months once weekly even if you don’t have the flares may help reduce chances of recurrence