Illustration: Angelica Alzona (Gizmodo)
Have you ever had a breakout that wouldn’t go away for weeks, maybe even months, no matter which products you threw at it? Did it consist of a lot of small bumps? Was it a little itchy?
What you had might not have been real acne at all, but a condition known as pityrosporum folliculitis. Though it looks nearly identical to bacterial acne, this breakout is caused by the fungus pityrosporum, also called malassezia — that’s why many have nicknamed it fungal acne.
“People call it fungal acne because it does look like acne,” Adam Friedman, a dermatologist at the George Washington University School of Medicine, told Gizmodo. “It can even confuse the well-trained eye of a dermatologist sometimes.”
Though it is cryptic and often escapes identification, pityrosporum folliculitis has been increasingly popping up on popular skincare forums, including Reddit’s r/SkincareAddiction, where a search for “fungal acne” yields hundreds of results. A frequently shared, comprehensive blog post on SimpleSkincareScience.com has become the authority on the condition, as it offers science-backed treatment advice and product recommendations. On the whole, it seems that fungal acne is one of the hottest new trends in skin care — check out the recent uptick in Google searches for “fungal acne”:
Google searches for the term “fungal acne” have surged since 2017.Screenshot: Google Trends
The first time someone on Reddit posted about fungal acne -- that we could find, anyway -- was back in October of 2013. "Curious as to why there is not much mention about FUNGAL acne," the poster mused, and then explained the condition. Since then, Redditors started posting about fungal acne and commenting on others' posts and photos, suggesting that their blemishes may be of fungal origin.
Then, in spring 2017, the Simple Skincare Science post went up. After that, as Google Trends shows, it was as if a fungal acne bomb had gone off. Many more people searched for it, and acne forum users continued to suggest that breakout pictures and descriptions held clues to a fungal invasion.
Malassezia infects hair follicles in a similar way that acne bacteria does. It hangs out down in the follicles, eating oils (whether produced by your skin or added by products) and causing inflammation. Sometimes, dead skin cells get trapped in the area, too. The result is a fungal breakout: often red or skin-coloured bumps, occasionally whiteheads, sometimes a mixture of both. Other signs of fungal acne are itchiness, and that all the "zits" appear at once, or are in similar stages, according to Friedman.
Because malassezia fungi love oil, they will most often congregate in the T-zone (forehead, nose, and chin), but also cause breakouts elsewhere on the face and on the chest, back, and shoulders. They also grow exceptionally well in warm, humid conditions, making pityrosporum folliculitis much more common in summertime and in hot, sticky climates (Singapore and the Philippines, both with warm and humid climates, have the highest rate of Google searches for "fungal acne"). Malassezia also thrives if you sweat a lot.
The trouble is, many people ID the condition as bacterial acne, and treat it as such. But that can inadvertently make the breakout worse. Long-term antibiotic use, which is sometimes prescribed to fight persistent acne, can change the skin's microbial community in a way that gives malassezia an advantage. And without the proper treatment, a fungal breakout can persist for years.
"Our skin is like a giant petri dish," Friedman said. "It sounds disgusting, but there are over 500 bacterial species, not counting virus or fungi. They're like an extra layer of protection, they fight off potential pathogens. They keep everything in check. But if you disrupt that balance, other things can take over."
And while using benzoyl peroxide and salicylic acid, two common over-the-counter topical treatments for bacterial acne, won't necessarily make the condition worse, they probably won't make it any better, since they don't target malassezia. Plus, as the post on cult-favourite blog Simple Skincare Science points out, those two products are often formulated with chemical compounds that malassezia feasts on, allowing the fungi to thrive even more.
Beyond curating your skincare products to cut out ingredients that feed the fungus (you can see a list of such ingredients here), Friedman suggested using dandruff shampoo on the affected area. Dandruff is also caused by malassezia fungus -- just by a different species of the bug -- so a shampoo like Head and Shoulders, which contains the antimicrobial ingredient zinc pyrithione, could help to fight off a fungal breakout. Even more effective are shampoos like Nizoral that contain a compound called ketoconazole, which is known to kill every species of malassezia. (Other species are associated with conditions including dermatitis and psoriasis.)
Of course, it's best to see a dermatologist to get a proper diagnosis; as we said, fungal breakouts versus bacterial acne can be impossible to distinguish by looks alone, and aggressively treating what you think is a fungal infection, but is really just regular acne, could make your acne worse. A dermatologist can scrape off a little sample of your breakout -- Friedman assured me that it's not painful -- and look at it under a microscope to confirm that you do indeed have pityrosporum folliculitis, not acne.
If pityrosporum folliculitis is the culprit, Friedman said he'll prescribe his patients the oral antifungal fluconazole, which is commonly prescribed for vaginal yeast infections. Though it's effective without any other intervention, he has another trick to really up its efficacy: "I tell a person to take it on day one and work up a sweat," he explained. "The medication will be concentrated in that sweat, and it's like you're bathing in it."
Anthony Rossi, a dermatologist at Memorial Sloan Kettering Cancer Center in New York, also prescribes antifungal meds to his patients with fungal acne. He notes that there are some risks associated with the medication, since it's processed through the liver.
"We council the patients on which drugs they're taking, and if they drink alcohol," he said. Drugs like Tylenol and antidepressants are also processed through the liver, and taking too many at once could cause damage.
Both Rossi and Friedman say that while a bout of pityrosporum folliculitis can last for many weeks, with the right treatment it can clear up in as little as 24 hours. Members of Reddit's r/SkincareAddiction have experienced this firsthand. Take this comment from user smallpaleawkward, for instance, in a thread about fungal breakouts: "... The main thing that clued me in to it being fungal? I just bought an antifungal and some sulphur and slapped that shit on my face. My face looked so much better the next day. Boom, diagnosis achieved."
Still, a major barrier to clearing up fungal breakouts is awareness and identification, among both doctors and patients.
"I think there is a gap, and that goes for patients, non-dermatology physicians, and even probably some dermatologists," Friedman told Gizmodo. "You're busy, you see like 10 cases of acne, and this 11th comes in, and you have tunnel vision."
So if you've had a persistent, bumpy breakout for a while, ask your dermatologist for a skin test -- you might be harboring an overgrowth of a not-so-cute little bug called malassezia.