How to treat fungal acne

What fungal acne is

Malassezia folliculitis is an infection in hair follicles caused by Malassezia yeast, which normally lives on skin. The yeast can cause trouble when it grows into a follicle. The nickname fungal acne saves syllables and creates a small diagnostic mess.34

It often appears as clusters of small, similar sized, itchy bumps, especially on the chest, back, shoulders, forehead or hairline. Some bumps are papules, meaning raised spots, or pustules, meaning spots containing pus. Itch is a useful clue, but it cannot confirm the diagnosis on its own.25

Anyone can get it, though it is commonly seen in adolescents and young adult males. Heat, humidity, sweat, oily skin, tight or occlusive clothing, greasy moisturizers or sunscreen, antibiotics, steroid use and a weakened immune system are among the factors linked with higher risk. If you take antibiotics or steroids, tell the clinician assessing the bumps rather than changing a prescription on your own.12

A primary care clinician or dermatologist can examine the skin and, when needed, check a scraping, swab or other sample under a microscope. A Wood lamp may also help. Testing matters because bacterial folliculitis and steroid related eruptions can look similar, and a rash that resembles acne does not identify its own cause.12

How to treat fungal acne

1. 1Ask a clinician to confirm the likely cause, especially if the bumps are itchy, persistent or have not improved with ordinary acne treatment.
2. 2For many cases, treatment starts with a topical antifungal. Options include selenium sulfide shampoo, econazole solution or topical ketoconazole; use the regimen given for the specific product and diagnosis.
3. 3If the condition is severe or does not clear, a clinician may prescribe an oral antifungal such as fluconazole or itraconazole. Oral treatment is not a do it yourself next step.
4. 4If breakouts recur, ask whether topical maintenance is appropriate. Ongoing weekly use is one maintenance option, particularly for people with repeated episodes or higher risk.

Topical antifungals are effective in many cases, but their course may need to be longer than a course of oral treatment. A review of 15 studies reported improvement in 92% of patients treated with oral antifungals and 81.6% treated with topical antifungals. Those are results across the reviewed studies, not a prediction for one person. Clinical trials have not consistently shown oral treatment to be more effective than topical treatment.25

Standard acne treatment does not treat a yeast infection in the follicles, and antibiotics can contribute to fungal acne or make it worse. Acne products can keep working very hard on a problem they were not built to solve. If a new breakout appears during antibiotic treatment, tell the prescribing clinician rather than assuming the answer is more acne treatment.5

Oral antifungals can cause diarrhea, nausea, vomiting, stomach pain and, in some cases, liver damage. Discuss the risks and your current medicines with the prescriber before starting oral treatment, and contact them about concerning side effects.1

Symptoms may clear within a few weeks after treatment starts, but recurrence is common. The bumps can return after treatment stops, and some people need a longer maintenance plan. Weekly topical use is a possible maintenance approach, not a universal starting schedule.4

Reduce the conditions that favor irritated follicles and yeast growth: shower and change clothes after exercise, wear loose clothing in heat, and avoid staying in sweaty or damp clothing. Wash swimwear after use and let it dry; use clean, well maintained hot tubs. Review whether greasy skin products, tight clothing, shaving or frequent rubbing could be contributing. Changing out of sweaty clothes promptly is not glamorous, but it is a practical way to avoid staying hot and damp.126

Fungal acne vs regular acne

Itch and uniform bumps point toward fungal folliculitis, while blackheads and whiteheads point toward common acne, but neither clue is a diagnosis. The two conditions can happen together. If itchy bumps persist or standard acne treatment has not helped, get the cause checked instead of adding more products.4

When to see a clinician

Arrange an assessment for an itchy breakout that does not go away, a rash that returns after treatment, or acne like bumps that have not responded to usual acne care. A clinician can check for Malassezia and other look alike conditions, then decide whether topical treatment, oral medicine or a recurrence prevention plan fits.4