Malassezia folliculitis, Pityrosporum folliculitis, tiny pimples that won’t respond to ANYTHING…Whatever you want to call it, fungal acne is real. And if your acne persists despite all the usual approaches, you may want to pay attention.

This surprisingly common condition has been overlooked until recently. This article covers the latest research into fungal acne, including why it happens, how to distinguish it from regular acne, and what to do to get rid of it for good.

Ready? Let’s begin.

Contents

What is fungal acne?
What causes fungal acne?
Other skin conditions associated with Malassezia
What are fungal acne symptoms?
What’s the treatment for fungal acne?
What’s the best fungal acne routine?
Do I need to eat an antifungal diet?
Takeaway points

What is fungal acne?

Fungal acne is caused by the overgrowth of Malassezia yeast on your skin, which creates lots of tiny, identical-looking pimples on your face and upper body [1]. This condition is also known as Pityrosporum folliculitis or Malassezia folliculitis [2].

Scientists have known about the Malassezia yeast since the 1800s, and fungal acne has been recognised medically since 1973 [3, 4]. The problem is this yeast is a sneaky fellow. Its pimples and inflammation are easily mistaken for normal acne vulgaris, which is why it so often slips under the radar.

Research into fungal acne has ramped up during the past two decades, and it’s becoming apparent that it’s more prevalent than we realised. If you’ve been dealing with acne-like breakouts for a while—and none of the standard approaches works—it may be that you have a fungal element going on.

What causes fungal acne?

Fungal acne is triggered by conditions that cause excessive yeast growth.

The Malassezia yeast is a normal part of your skin microbiome. Some of its 18 known species start colonising babies as soon as they’re born, and they hang out on the skin of 92% of healthy adults [5, 6].

Malassezia only turns into fungal acne when its environment enables it to grow too much. Instead of residing harmlessly on your skin surface, it gets down into your hair follicles. There, it feeds on fatty acids in your skin oil, enabling it to proliferate [7]. This rapidly expanding yeast population produces irritants and ruptures the walls of hair follicles—triggering a big ol’ inflammatory reaction [5]. Hello, lots of tiny pimples.

When you have a microbial imbalance in your gut, we call it ‘dysbiosis’. Fungal acne is the same thing playing out on a different surface—so it’s dysbiosis of the skin.

But what drives the imbalance?

Lots of factors can set the condition for Malassezia overgrowth, including:

1) Humidity

Yeasts love a warm, moist environment, so it’s no surprise that fungal acne is more common in humid places. A study in the Philippines—where there’s an average humidity of 75%—found that more than half of acne patients have a Malassezia problem [8].

Fun fact: when researchers want Malassezia to grow in a petri dish, they create humidity by setting the temperature to 31–35C and popping the dish in a plastic bag! [9]

2) Occlusion

This is a fancy word to mean ‘blockage’. It applies to everything from blocked pores to tight fabrics that block airflow. This means that make-up, thick sunscreens and even your cute athleisure wear can promote a flare of fungal acne [10].

3) Sweating

Much like heat and humidity, sweat creates the perfect conditions for yeast to grow [11]. So, pair that occlusive athleisure wear with a sweaty workout—and you set the stage for a Malassezia party.

4) Use of antibiotics

Just as antibiotics can affect bacterial populations in your gut, they also change bacterial populations on your skin [12]. If you kill off some good skin bacteria, you create space for more yeast to grow—leading to fungal acne [10].

5) A weakened immune system

Whether in your gut or on your skin, your bodily microbes are kept in check by your immune system. If your immune system is suppressed in any way, opportunistic microbes—including Malassezia—start to run riot [3]. A suppressed immune system occurs in people with HIV/AIDs, and it is also a side effect of certain medications [13]. Stress and nutritional deficiencies can affect your immune system function too.

Fungal acne is also more common in people with diabetes [14]. This is because uncontrolled diabetes affects the immune system. It may also be because the excess insulin seen in uncontrolled diabetes leads to oilier skin—giving Malassezia lots of food to fuel its takeover. More on this later.

What are fungal acne symptoms?

Fungal acne appears as clusters of small whiteheads or red bumps, typically 1–2mm in diameter [17]. As Malassezia loves to feed on sebum (skin oil), these pimples crop up around hair follicles in the oily areas of the body, including the:

– Face (especially the T-zone and around the hairline)

– Back

– Chest

– Upper arms [13]

Some people find that the pimples itch, but not everyone [18].

The tricky thing about fungal acne is that it’s often mistaken for regular acne. To add to the confusion, you can have both regular acne and fungal acne at the same time [19]. The problem is that standard acne treatments won’t work for fungal acne. In fact, they can wind up making it worse [10].

A GP or dermatologist can diagnose fungal acne based on your symptoms alone, or by sending off a small specimen of your skin lab analysis. But you can also be your own detective. Here are some clues to help you distinguish between fungal acne and regular acne:

What’s the treatment for fungal acne?

At the time of writing, there’s no internationally approved treatment guideline for fungal acne [5]. This lack of standardisation is part of the reason the condition is so under-recognised.

In studies, researchers have found that topical antifungals (such as a gel or lotion) can help to reduce symptoms. But it’s often not enough. As the Malassezia yeast can hide in the deepest part of the hair follicles, antifungal medications may need to be taken too [20].

The trouble is many fungal acne cases are mistaken for regular acne, and antibiotics are dished out. Antibiotics ravage your skin’s friendly bacteria, further driving skin dysbiosis and making fungal acne worse [10].

Even with the correct antifungal treatment, there’s a high rate of reoccurrence [5]. Your liver doesn’t like repeated doses of antifungal medications, though, so it’s not advisable to rely on those each time you have a flare.

So, what can you do?

Remember, fungal acne develops when the environment enables Malassezia to overgrow. Change the environment in your body, and you’ll see changes on your skin.

What’s the best fungal acne routine?

As with any skin condition, the best way to tackle fungal acne is from the inside and the outside. Outside approaches can give you more immediate symptom relief, while inside approaches help you to create a longer-term resolution.

With fungal acne, the goal of both the inside and outside approaches is to minimise Malassezia overgrowth and rebalance the skin microbiome. Don’t worry—it’s much simpler than it sounds!

Inside approaches

Let’s explore the simple steps you can take:

1) Balance your blood sugar

If you’ve read my other articles, you’ll know that this is my number-one tip for clear skin, no matter your complexion woes.

When your blood sugar is up and down, it leads to surges of insulin. These surges of insulin start a hormonal cascade that winds up making your skin oilier [21]. And you know how Malassezia loves to feed on skin oil.

By balancing your blood sugar, you keep your insulin nice and steady—and make your skin naturally less oily. Less oil = less food for Malassezia = less fungal acne.

Balancing your blood sugar is easy. It means:

– Eating some protein or healthy fat with every meal

– Choosing wholegrains instead of white grains, and cutting down on sugar

– Loading up on fibre-rich vegetables and fruit

Eating a blood-sugar-balancing meal isn’t going to solve your fungal acne overnight—but, over time, it’s an essential step in shifting that environment.

2) Optimise your microbes

We don’t know exactly how, but we know that the microbes in your gut and the microbes on your face are connected. That means that optimising your microbes on the inside can help to shift your microbes on the outside.

First, consider a natural antifungal to help beat back yeast overgrowth. Studies show that oregano oil and caprylic acid are particularly effective [22, 23]. You don’t want to take these for long periods of time—certainly no more than eight weeks—as they are potent agents.

Next, take probiotics to help create a more friendly, balanced microbial environment. It seems counterintuitive, but animal studies show that a probiotic yeast called Saccharomyces boulardii can help to knock other yeasts back into place [24]. Probiotics that include Lactobacillus strains have antifungal action too [25].

You should always check with your doctor before starting any new supplements.

3) Support your immune system

Malassezia is a wily little yeast. If your immune system is at a bit of a low ebb, it takes the opportunity to grow—knowing that it’s less likely to meet resistance.

Supporting your immune function is an important step in reinstating microbial balance. And it needn’t be difficult! The simplest actions are often the most powerful. Focus on:

– Prioritising your sleep

– Making time for relaxation

– Getting regular exercise

– Enjoying sensible sun exposure

– Eating well

As an extra insurance policy, you could consider a high-quality multi-nutrient that contains both zinc and vitamin D—nutrients that are essential for healthy immune function [26]. But remember: supplements should only ever be the cherry on top. Make sure you get the basics right first.

Together, these approaches will help you shift your body’s environment, making it harder for Malassezia to dominate. Eating your vegetables, popping a probiotic or getting a bit of extra kip may not feel like a dramatic shift—but it is. Over the long term, these actions make the secret sauce that helps you beat fungal acne for good.

Outside approaches

Remember how we said that fungal acne is dysbiosis of the skin? What you put on your skin also has a role to play in creating that all-important microbial balance.

Here’s what you should pay attention to on the outside:

1) Avoid putting oils on your skin

Malassezia loves nothing more than a big ol’ greasy buffet. Specifically, it likes to feed on fats with a 12, 13 and 14-atom carbon chain [10]. These types of fats are typically known as:

– Lauric acid

– Tridecylic acid

– Myristic acid

These fatty acids are in a range of natural oils, and their esters (called laurate, tridecanoate and myristate) are also in many skincare products. This means two things:

1) It’s a good idea to start reading skincare ingredients labels

2) It’s a bad idea to use oil-rich products (and that includes lauric acid-rich coconut oil)

One exception to this no-oil rule is squalane oil. This is a more stable version of the squalene that occurs naturally in your sebum [29]. Squalane doesn’t feed Malassezia, but it is an effective emollient (moisturiser) and can help to support your skin’s barrier. A strong skin barrier is an important part of beating Malassezia irritation.

Want further product recommendations? I share my favourite fungal acne-safe skincare in The Happy Skin Roadmap.

The funny thing about skincare is that you may need to tweak it according to your external environment. A moisturiser with a bit of myristic acid might be fine in a cold climate but, as soon as you travel somewhere hot and humid, it contributes to a fungal acne flare. Don’t be afraid to experiment and see what works for you, which leads me to my next point…

2) Slim down your skincare routine

Regular readers will know I’m a big advocate for paring back your routine (and I’m not alone!). Studies show that molecules from skincare hang around on your skin for weeks or months, no matter how much you wash [30].

Not only that, but researchers are also beginning to question whether preservatives (used in skincare to increase their shelf life) are killing friendly skin bacteria, contributing to dysbiosis and setting the stage for Malassezia overgrowth [31].

Preservative-free skincare is rare in the consumer market, simply because it could become overrun with bacteria and unsaleable. So, to lessen your preservative load, your options are to either mix up fresh skincare from your fridge each day or simply use fewer products. If you’re a busy person, the second option is a no-brainer.

To start, why not try skipping cleanser in the morning? As long as you cleansed your face well the night before, a gentle splash with warm water is all that’s needed to refresh your skin.

Head to this article for more tips on looking after your skin microbiome.

3) Use targeted antifungal agents

Yes, you want to slim down your skincare routine, but you also want to make the most of the products and ingredients that can help your skin reset. Four spring to mind:

a) Zinc pyrithione

This form of zinc is antifungal and often used to treat seborrheic dermatitis, another condition caused by Malassezia [13]. It’s also the active ingredient in many dandruff-beating shampoos (another condition associated with Malassezia). But don’t put shampoo on your face! Instead, look for a face wash with 2% zinc pyrithione. Be aware that the pyrithione bit is important—other forms of zinc (such as the skincare-favourite zinc sulphate) don’t have the same effect.

Update 2023: the use of zinc pyrithione in cosmetics is now banned in the EU due to its association with reproductive toxicity. Even if you live outside Europe and are able to purchase zinc pyrithione-containing products, I no longer recommend their use.

b) Tea tree oil

Studies in petri dishes show that Melaleuca alternifolia (tea tree oil) can stop the growth of some Malassezia species [32, 33]. This means tea tree oil is one of the few oils you do want to put on your skin. Never apply it neat, as it can be irritating. Either apply it with a carrier such as aloe vera gel, or use a pre-blended product that’s been formulated with tea tree oil’s dermal limit in mind.

Neither zinc pyrithione nor tea tree oil should be used indefinitely, as they can also kill off some of the good guys on your skin. Once you have your complexion under control, gradually pare back your usage of these ingredients so that you’re only applying them once or twice a week for maintenance.

c) Raw, organic honey

A study of 30 people with seborrheic dermatitis (yes, there’s that pesky Malassezia again) found that applying raw honey every other day helped to clear skin within a month [34].

In this particular study, they left the honey on for 3 hours at a time. If you don’t have time for that (and who does?), simply massage raw, organic honey onto your face and leave it on for a couple of minutes while you brush your teeth. That’s a good start. There are no studies proving that this works for fungal acne, but there are some anecdotal accounts that it helps.

d) Apple cider vinegar

Apple cider vinegar is a known antifungal agent, and one petri-dish study from 2019 found that it could inhibit Malassezia at a concentration of 40% [35]. In practice, this would mean mixing 40ml of apple cider vinegar with 60ml water, and either spraying a little onto the affected area of applying it with a cotton pad. If you can put up with a slight vinegary aroma, it’s worth a try.

Pair this outside routine with your inside approaches, and you’ll be well on your way to saying goodbye to fungal acne for good.

Takeaway points

Well done for reaching the end! Let’s summarise what we’ve learnt:

– Fungal acne occurs due to the overgrowth of Malassezia yeast on your skin.

– Malassezia is a normal resident of your skin microbiome, but it can turn pathogenic if conditions allow it to grow too much.

– Factors that encourage Malassezia growth include humidity, occlusive cosmetic products and clothing, sweating, use of antibiotics and a weakened immune system.

– Fungal acne appears as lots of tiny, identical-looking whiteheads or red bumps. They show up on oily areas of your body, such as your face, chest and back.

– Conventional treatment for fungal acne includes topical and oral antifungals, but the fungal acne often ends up coming back.

– To beat fungal acne for good, you need to change the environment on your skin so that Malassezia can’t overgrow. This involves making changes on the inside and the outside.

– Inside changes include balancing your blood sugar, optimising your bodily microbes and supporting your immune system.

– Outside changes include avoiding using oils on your skin, slimming down your skincare routine and using targeted antifungal agents.

Want to conquer fungal acne for good? Get your copy of The Happy Skin Roadmap.