Fungal acne: when pimples are not acne

Key takeaways

• Fungal acne is not true acne. It is an infection of hair follicles by a yeast that normally lives on everyone's skin.
• Clues: itch, bumps all the same size, no blackheads, and worse in heat and humidity.
• Antibiotics, which are often given for acne, can make it worse.
• Treatment uses antifungal washes or, if needed, antifungal tablets prescribed after assessment.
• It often returns, so a simple weekly maintenance wash is part of the plan, especially in Mumbai's monsoon.

What is fungal acne, really?

Let me start with the name, because it causes confusion. Basically, fungal acne is not acne. The correct name is malassezia folliculitis, also called pityrosporum folliculitis.

Malassezia is a yeast that lives on almost everyone's skin, feeding on skin oil. Normally it causes no trouble. DermNet explains that under certain conditions it overgrows inside the hair follicle and causes small, itchy bumps and pustules. The same yeast is behind pityriasis versicolor, the patchy white or brown rash many people in coastal India get on the chest and back.

How do I know it is fungal and not regular acne?

In my clinic, the story is often very typical. "Doctor, I have been on acne tablets for a month and it is worse. And it itches." That combination is a strong clue.

DermNet lists the main risk factors: hot, humid climate, oily skin, heavy sweating, occlusive creams and sunscreens, antibiotic use, and immune suppression including steroid creams or tablets. Many of my patients have more than one. A young man who goes to the gym, commutes in the rain, and was given antibiotics for pimples is a very common picture.

The two can also exist together. Some people have normal acne on the face and fungal folliculitis on the back. That is why I prefer examining the skin rather than guessing from a photo.

How is it diagnosed?

Often the pattern is clear on examination. When I am not sure, a simple skin scraping looked at under the microscope can show the yeast. DermNet notes it is frequently mistaken for acne, steroid acne or bacterial folliculitis, which is exactly why a quick test is sometimes worth doing before starting long treatments.

Why do steroid creams make it worse?

This is an important Indian issue. Many people buy mixed creams over the counter that combine a steroid with an antifungal and an antibiotic. The steroid calms the itch for a few days, so the cream feels like it is working. See, what happens is, the steroid also suppresses the skin's defences, and the yeast keeps growing. An Indian review on the dermatophyte (ringworm) epidemic in IJDVL describes steroid combination creams as a major cause of chronic, stubborn fungal infections. If you are using any such cream, please stop and bring it with you. My article on the hidden steroid problem in fairness and mixed creams explains more.

How is fungal acne treated?

The aim is to reduce the yeast, and to fix whatever is helping it grow. Options, decided after assessment, include:

1. Antifungal washes and shampoos used as a body wash. Ketoconazole or selenium sulfide shampoo is lathered on the affected skin, left for a few minutes, then rinsed. DermNet describes this approach for malassezia infections.
2. Antifungal creams or solutions for smaller areas.
3. Antifungal tablets for widespread or stubborn cases. DermNet notes oral antifungals may work better than topicals, with fluconazole often preferred for its side-effect profile. Tablets are a prescription decision and need a check of your other medicines and health.
4. Stopping the triggers. Stop unnecessary antibiotics and steroid creams, switch heavy creams for lighter gels, and change out of sweaty clothes quickly.

Normally the itch settles first, within a couple of weeks. The bumps take longer. If there are leftover dark marks, those fade separately over weeks to months.

Why does it keep coming back, and how do I prevent it?

DermNet is clear that recurrence is common, even after successful treatment. The yeast is part of your normal skin, so we cannot remove it forever. We can keep it in balance. What I usually suggest: - Use the antifungal wash once a week as maintenance, more often during the monsoon if your doctor agrees. - Shower soon after sweating, and dry the skin well before dressing. - Wear loose cotton clothing, especially for long commutes. - Avoid thick, oily body lotions and heavy oil-based sunscreens on the back and chest. - Never restart a steroid cream for an itch without being examined.

My article on monsoon skin care has a fuller routine for the rainy months. For true acne on the body, see back and chest acne.

How we approach this at Dr Tvacha

Acne and its look-alikes are a regular part of our skin work at the Thane, Andheri, Bandra and Dahisar centres. Under the Second Layer Skin Plan, I examine the bumps, ask about antibiotics, steroid creams and your daily routine, and arrange a scraping or other tests only if they will change the treatment. Tests are charged at actual cost. You leave with a written plan for both treatment and maintenance, so you know what to do the next time the weather turns humid.

Written by

Dr Amit KarkhanisAesthetic Physician · MBBS, Dip. Dermatology (UK) · Reg. No. 2001/02/1124

Founder of Dr Tvacha, practising in Thane since 2005. Leads the weight loss and hair programmes.