Accurately distinguishing between fungal acne and acne vulgaris is the key to therapeutic success. Read more...
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What is fungal acne? How is it different from regular acne?
Accurately distinguishing between fungal acne and acne vulgaris is the key to therapeutic success. Fungal acne treatment is different from regular acne.
Here is the breakdown...
Medically referred to as Pityrosporum folliculitis (caused by Malassezia species) Location
Anywhere there is a hair follicle- similar locations to traditional acne but often more extensively through the full length of the back (as opposed to the upper back for acne) and along the sides of the neck.
Monomorphic hair follicle-based papules and shallow pustules. I describe this to patients as though all of the breakouts almost appear as though they are in the same or similar stage of development. We do not often see large cystic papules along with shallow pustules as you do with acne. There is a goosebump-like texture to the skin with the feel as though many of the hair follicles are inflamed simultaneously. Open and closed comedones (whiteheads and blackheads) are not really appreciated as the main cause. Often patients will say they just “scratch the bumps off”.
+/- Itch. Not necessarily tender or painful
Temperature variations, sweating
Cutibacterium acnes, formerly known as Propionibacterium acnes (P. acnes)
Face, Upper back, Shoulders, Chest
Comedones, open and closed, in the background. Inflammation can accompany the comedones. Each spot can be in varying stages - some as comedones with no inflammation, some with some inflammation, and others can be cystic. Patients will often say they can get the satisfaction of “popping a pimple” by squeezing these
+/- tender or painful based on the stage of development
Hormonal changes, physical blockage of pores.
Face, Upper back, Shoulders, Chest
Anywhere there is a hair follicle
Comedones, open and closed +/- Inflammation +/- Cysts
Monomorphic hair follicle-based papules and shallow pustules
+/- tender or painful based on stage of development
+/- tender or painful based on stage of development +/- Itch
Not necessarily tender or painful
Hormonal changes Physical blockage of pores
Temperature variations Sweating
Can you speak to how trapped moisture (ex: wearing sweaty workout clothes) can lead to fungal acne?
With exercising, hormonal fluctuations, or while in humid environments, sweat can build up on our skin and become trapped underneath clothing. This sweat is intended to work as a thermoregulatory mechanism to cool our skin down by evaporating off our skin. If it does not evaporate, it can create an environment that allows yeast to flourish or overgrown.
Functional textiles have become very popular as we look to clothing to multitask. Cooling textiles and moisture-wicking textiles generally act by regulating sweat evaporation or absorption. Our body’s natural cooling mechanism or innate ability to cool down is based on the production of sweat that then evaporates off the skin and cools it down.
Textiles that function to do so can work in a couple of ways. The first is that the construction of the textile can result in the ability to wick away moisture from our skin to speed the cooling mechanism that sweat plays in bringing our temperature down. There is often a fine layered construction that allows the sweat to move through the fabric through osmotic pressure and the capillary action between the layers. By doing so the moisture is not just absorbed by the fabric, it is actually released into the air. The other way this can be achieved is through producing textiles with crystals embedded in the construction of the textile. These crystals serve a similar role. They absorb sweat to allow the skin to cool quickly.
These fabrics are effective and much more comfortable to wear for those that deal with excess body heat, hot flashes, or spend a lot of time outdoors. Cotton is a commonly sought summer textile but it absorbs sweat and holds it in the fabric. The fabric is touted to “breathe” when it's dry but when it's wet with sweat it can start to feel uncomfortable as it holds the moisture in the fabric.
Is fungal acne contagious?
Technically neither acne vulgaris (caused by Cutibacterium acnes, formerly known as Propionibacterium acnes) nor fungal acne (caused by Malassezia species) is considered contagious. Both organisms are considered commensal organisms part of our normal bio flora. The pathophysiology of both types of breakouts is likely either a buildup of excess bacteria or yeast, an increase in the oil content on the skin providing the organisms with more resources to expand their growth, and/or an immune response to the presence of the bacteria or yeast. Theoretically, I supposed fungal acne could be considered in the contagious category if referring to Tinea barbae (fungal infection in the beard area caused by Trichophyton species of fungus.
Are there any other causes of fungal acne?
Taking steroids (decreasing our immune response to fungus and bacteria) and/or taking antibiotics to treat acne vulgaris (changing the skin’s bio flora and allowing the yeast to overgrow) are other causes of fungal acne.
What does fungal acne look like compared to bacterial acne?
Each fungal acne lesion tends to be pinhead-sized. Bacterial acne can range from a dilated pore to a sandpaper-like bump to an inflamed papule about the size of a pencil head eraser to a cystic nodule the size of a gumball.
Can you speak to the location of fungal acne? Where does it typically show up?
Fungal acne can occur anywhere there is a hair follicle- similar locations to traditional acne but often more extensively through the full length of the back (as opposed to the upper back for acne) and along the sides of the neck. I often point out to patients the extent of involvement across the back and along the sides and back of the neck. It also occurs in areas typical for acne such as the forehead, cheeks, and chest.
Can you speak to how fungal acne can cause discomfort/itchiness? How is this different from bacterial acne?
Fungal acne can be associated with itchiness likely from an immune response to the presence of yeast in our pores. Acne can be itchy but is more commonly either tender or sore once inflamed.
Any other characteristics of fungal acne that would help us figure out if what we have is fungal acne?
A true diagnosis is generally made by taking a step back and looking at the whole picture: location of the breakouts, characteristics of each lesion, and scenario that triggered a flare. This is where it is important for our patients to not just point out their faces but to also comment on the neck, back, and chest. Important diagnostic clues can be achieved by looking at the whole picture.
How long does fungal acne usually last?
Fungal acne can last forever - it will not necessarily impact your general health, it will serve instead as a constant source of frustration, and discomfort and be potentially unsightly. It can also fluctuate based on seasons as opposed to hormonal changes. This can vary from traditional acne which can affect teenagers with the hope that many will “outgrow” it by a certain age.
Can you provide some OTC treatments for fungal acne?
Fungal acne can often respond to similar treatments and approaches as seborrheic dermatitis. Starting with OTC options is very reasonable understanding that if there is no response within a couple of weeks, seeking out an appointment with a Board Certified Dermatologist is important.
I often recommend considering to use of Vanicream Z bar (which contains 2% zinc pyrithione) especially after exercising can work as an anti-yeast agent to reduce its spread and growth.
Any other treatments you recommend for fungal acne?
It is not unreasonable to attempt to use Nizoral shampoo (the OTC version is 1% ketoconazole) over the affected areas. The prescription option is 2% which can be considered if treatment fails. Otherwise, we often treat with ketoconazole 2% cream available as a prescription.
Can you speak to how wearing breathable fabrics minimize the risk of getting fungal acne?
Breathable fabrics encompass many types of textiles but often reference the weave of the textile. There is often a fine layered construction that allows the sweat to move through the fabric through osmotic pressure and the capillary action between the layers. By doing so the moisture is not just absorbed by the fabric, it is actually released into the air. The other way this can be achieved is through producing textiles with crystals embedded in the construction of the textile. These crystals serve a similar role. They absorb sweat to allow the skin to cool quickly.
Anything you can recommend to prevent fungal acne?
I recommend a few steps to try to reduce the chances of a case of fungal acne:
Rinse off and change after exercising to avoid a buildup of sweat on the skin
Use a zinc pyrithione-based soap or shampoo as a body wash 2-3 times a week to reduce the buildup of yeast on the skin.
Keeping a fan positioned close to workout areas or at night while sleeping cools the skin quickly when nightly hot flashes may be experienced.
Don’t just focus on clothing while sweating- remember your bedsheets!! Our skin spends 33% of its time in bedsheets and people rarely think about this impact on the skin. Percale bed sheets based on the weave can allow heat to escape the skin and not build up to allow the yeast to overgrow.