Fungal acne (Malassezia folliculitis)

Overview

"Fungal acne" is a misleading name. It's really Malassezia folliculitis, an irritation of the hair follicles caused by an overgrowth of a yeast that normally lives on everyone's skin. It is not regular acne, but the two are easy to confuse because both look like small bumps and both flare on oily skin. Here's the catch: standard acne antibiotics can actually make fungal acne worse, which is why people who don't clear up on those medications often turn out to have this instead.

Evidence anchors

• review

  Rubenstein RM, Malerich SA. Malassezia (pityrosporum) folliculitis. J Clin Aesthet Dermatol. 2014;7(3):37-41.

  PMID:24688625View source ↗
• review

  Rubenstein RM, Malerich SA. Malassezia (Pityrosporum) Folliculitis [full text]. J Clin Aesthet Dermatol. 2014;7(3):37-41.

  PMC3970831View source ↗
• retrospective cohort

  Prindaville B, Belazarian L, Levin NA, Wiss K. Pityrosporum folliculitis: A retrospective review of 110 cases. J Am Acad Dermatol. 2018;78(3):511-514.

  PMID:29138059View source ↗
• systematic review

  Vlachos C, Henning MAS, Gaitanis G, Faergemann J, Saunte DM. Malassezia folliculitis: A retrospective review of 110 cases [systematic review and treatment-outcome synthesis]. Arch Dermatol Res. 2022;315(6):1497-1509.

  PMID:36517586View source ↗
• mechanistic

  Reeder NL, Kaplan J, Xu J, Youngquist RS, Wallace J, Hu P, et al. Zinc pyrithione inhibits yeast growth through copper influx and inactivation of iron-sulfur proteins. Antimicrob Agents Chemother. 2011;55(12):5753-60.

  PMID:21947398View source ↗
• mechanistic

  Park M, Cho YJ, Lee YW, Jung WH. Understanding the Mechanism of Action of the Anti-Dandruff Agent Zinc Pyrithione against Malassezia restricta. Sci Rep. 2018;8(1):12086.

  PMID:30108245View source ↗
• mechanistic

  Choi JH, Jeong YS, Lee YW, Park S, Jung WH. Long-Chain Acyl-CoA Synthetase Is Associated with the Growth of Malassezia spp. J Fungi (Basel). 2019;5(4):112.

  PMC6958399View source ↗
• review

  Park M, Park S, Jung WH. Skin Commensal Fungus Malassezia and Its Lipases. J Microbiol Biotechnol. 2021;31(5):637-644.

  PMC9705927View source ↗
• RCT

  Faergemann J, Jones JC, Hettler O, Loria Y. Pityrosporum ovale (Malassezia furfur) as the causative agent of seborrhoeic dermatitis: new treatment options. Br J Dermatol. 1996;134 Suppl 46:12-15 (15% propylene glycol vs vehicle, 89% vs 32% clearance).

  PMID:2974411View source ↗
• review

  Suzuki C, Hase M, Shimoyama H, Sei Y. Treatment Outcomes for Malassezia Folliculitis in the Dermatology Department of a University Hospital in Japan. Med Mycol J. 2016;57(3):E63-E66.

  PMID:27581777View source ↗
• review

  Iatta R, Cafarchia C, Cuna T, Montagna O, Laforgia N, Gentile O, et al. Bioprospecting yeast Malassezia furfur: a source of azelaic acid. Mycopathologia. 2014;179(3-4):245-251 (azelaic acid is itself a Malassezia metabolite with reversible enzyme-inhibition activity).

  PMID:39464747View source ↗
• patient education

  Cleveland Clinic. Pityrosporum (Malassezia) Folliculitis: Causes, Symptoms & Treatment.

  ClevelandClinic-22833View source ↗

Ingredients that help

• Zinc Pyrithionestrong

  Kills the yeast (Malassezia) behind fungal acne. It floods the yeast cells with copper to toxic levels and shuts down the parts they need to breathe. It is an FDA-approved over-the-counter dandruff ingredient, and people use it off-label as a 1-2% face or body wash (lather, leave on 3-5 minutes, then rinse). For the related condition dandruff (seborrheic dermatitis), trials show it works about as well as 2% ketoconazole.

  PMID:21947398
• Salicylic Acidmoderate

  Clears the plug of dead skin and oil blocking the follicle, which opens it up so antifungal treatments can reach the yeast and takes away the trapped, oily spot the yeast needs to grow. Salicylic acid dissolves in oil, so it gets down into the follicle. At higher strengths it fights the yeast a little directly, but its main job is clearing that plug. It is a top add-on after you have cleared the yeast, and a common ingredient in fungal-acne body washes.

  PMID:24688625
• Azelaic Acidmoderate

  Slows the growth of the yeast behind fungal acne and fades the dark marks a flare leaves behind. Fittingly, azelaic acid is something the yeast itself makes (it was first found in Malassezia furfur). In lab tests it blocks the energy the yeast needs to grow. It is a useful daily leave-on for upkeep.

  PMID:39464747
• Hypochlorous Acidemerging

  Knocks back bacteria and fungi at the low strengths used in skincare (about 0.01-0.05%) without harming your skin barrier. It is a handy spray to reset your skin after a workout, after shaving, or before your routine if you are prone to fungal acne. It is not a replacement for an antifungal like ketoconazole or zinc pyrithione, but it is a gentle add-on that does not feed the yeast.

  PMID:24688625
• Propolisemerging

  Helps damage the yeast behind fungal acne. Propolis is a bee resin, and in lab tests it breaks down the structure of several Malassezia yeast species. Most of the proof so far is from lab or animal studies. It is a useful supporting ingredient, not a main treatment.

  PMC10975792

Ingredients that aggravate

• Camellia Oil

  Camellia seed oil is about 80% oleic acid, plus linoleic and palmitic. All three are fats the yeast (Malassezia) can feed on, so this oil can fuel a flare.

• Sea Buckthorn Oil

  Sea buckthorn oil is rich in palmitoleic acid (the well-known omega-7), plus palmitic, linoleic, and alpha-linolenic. These are all fats the yeast feeds on, so it can fuel a flare even though the oil calms inflammation in other settings.

• Rosehip Oil

  Rosehip seed oil is mostly linoleic acid (about 45%) and alpha-linolenic acid (about 30%). Both are fats the yeast can break down and feed on directly.

• Marula Oil

  Marula oil is 70-78% oleic acid, plus stearic and palmitic. These are classic fats the yeast feeds on, despite the oil's other benefits.

• Argan Oil

  Argan oil is about 45% oleic acid and 35% linoleic acid. Both are fats the yeast feeds on.

• Jojoba Oil

  Jojoba is a liquid wax made of long fats. Their lengths sit at the upper end of what the yeast can use. Most people in the fungal-acne community avoid it during an active flare. The proof is less clear-cut than for plant oils because jojoba's bonds are harder for the yeast to break, but it is safest to skip it while you are treating a flare.

• Tamanu Oil

  Tamanu oil is rich in oleic acid (about 40%) and linoleic acid (about 30%), both fats the yeast feeds on. It is a useful spot treatment in other situations, but skip it during a fungal-acne flare.

• Shea Butter

  Shea butter is 40-55% oleic acid and 35-45% stearic acid. Both are fats the yeast feeds on. Shea butter also has anti-inflammatory plant compounds, but those do not cancel out the feeding effect of its fats.

• Linoleic Acid

  Pure linoleic acid is the exact fat the yeast eats best. It is helpful for regular (bacterial) acne, since that skin tends to be low in it, but it actively makes a fungal-acne flare worse.

• Lanolin

  Lanolin is a wax whose fats closely match the natural oils in human skin, which is exactly what the yeast evolved to live on. Skip it during a flare.

• Beeswax

  Beeswax is made of fats the yeast can use, bonded to very long alcohols. Those long alcohols and its high melting point make it harder for the yeast to feed on than a free oil, but the fungal-acne community still flags it during a flare. Treat it as borderline.

• Honey

  The evidence is mixed. Above 12% honey can slow the yeast's growth in lab tests (from its peroxide and high sugar content), but at the lower amounts in most leave-on products the sugar may instead feed the yeast. People also commonly report honey as a fungal-acne trigger. Treat it as borderline. It is fine in a short, rinse-off mask, but be cautious leaving it on during an active flare.

• EGCG (Green Tea)

  Green tea LEAF extract (EGCG and other polyphenols) is fungal-acne-safe. This entry is here only to clear up confusion: the camellia SEED OIL (id 42) is what feeds the yeast, while this green tea LEAF extract (id 57) does not. Nothing to avoid here.

Suggested routine

Watch out for these on labels

Specific irritants from our watchlist that the research pack identifies as aggravating for fungal acne (malassezia folliculitis).

Products from our catalog

• Paula's Choice · Skin Perfecting 2% BHA Liquid ExfoliantTreatment

  A 2% salicylic acid leave-on. It clears the clogged follicle so antifungal treatments can reach the yeast. It is the most-recommended add-on in fungal-acne routines.

  View retailer ↗
• COSRX · BHA Blackhead Power LiquidTreatment

  A budget 2% salicylic acid leave-on that does the same job.

  View retailer ↗
• Naturium · Azelaic Topical Acid 10%Serum

  10% azelaic acid. It is a substance the yeast itself makes, and in lab tests it slows the growth of Malassezia furfur. It also fades the dark marks left after a flare. Useful daily for upkeep.

  View retailer ↗
• The Ordinary · Niacinamide 10% + Zinc 1%Serum

  10% niacinamide. It calms the redness left after a flare and does not feed the yeast, since it is a water-soluble vitamin with no fats for the yeast to eat.

  View retailer ↗
• Beauty of Joseon · Relief Sun: Rice + Probiotics SPF 50+ PA++++SPF

  A mineral sunscreen with rice-bran extract, giving broad protection in a fairly light formula. Check the ingredient list when you first buy it, since sunscreen formulas sometimes change.

  View retailer ↗
• Round Lab · Birch Juice Moisturizing UV Lock Sunscreen SPF 45SPF

  Another mineral sunscreen option. It is lightweight and gentle on inflamed skin.

  View retailer ↗
• La Roche-Posay · Anthelios Mineral Tinted SPF 50SPF

  A tinted mineral sunscreen. It is handy when dark marks from a past flare are showing and you want some coverage without a heavy, oily foundation.

  View retailer ↗

Ingredients to consider adding

Not yet in our catalog. Surfaced here as editorial backlog.

• Ketoconazole

  An antifungal that blocks the yeast from building a fat (ergosterol) it needs for its cell walls. The shampoo (Nizoral A-D is 1% over the counter; 2% is by prescription in the US and over the counter in much of Europe and Asia) is the first-choice dermatologist pick for fungal acne and the benchmark in most antifungal trials. Used as a leave-on wash (3-5 minutes of contact) it clears most people's skin in 14-28 days. It is the single most-recommended fungal-acne treatment.

• Selenium Sulfide

  An over-the-counter antifungal (Selsun Blue Medicated, Head & Shoulders Clinical Strength). It does three things at once: it fights the yeast, clears the dead skin clogging the follicle, and slows the skin cells lining the follicle from building up. In a trial against 2% ketoconazole it eased dandruff symptoms about as well at 4 weeks. It is cheap, easy to find, and often recommended for fungal acne on the body and back.

• Ciclopirox Olamine

  An antifungal from a different chemical family than ketoconazole and other azoles, so it is useful when the yeast may have stopped responding to those. In a blinded trial for scalp dandruff, 93% of people on ciclopirox cleared up versus 41% on placebo. In lab tests, pairing it with zinc pyrithione kills more yeast than ketoconazole alone. It also calms inflammation more than several azoles and hydrocortisone (a mild steroid).

• ItraconazoleRx only

  An antifungal pill, the dermatologist's go-to when fungal acne is stubborn or widespread (usually 200 mg a day for 1-3 weeks, or in pulses). In head-to-head data it works better against the yeast than fluconazole. Prescription only.

• FluconazoleRx only

  An antifungal pill taken once a week (150-300 mg). It is less reliable than itraconazole against the yeast, but it is easier on the liver and the option doctors most often prescribe for stubborn cases. Prescription only.

• Sulfur

  A long-used over-the-counter treatment that at 3-10% fights the yeast, clears dead skin, and curbs bacteria. It is part of sulfacetamide/sulfur washes (Plexion, Klaron) that dermatologists use for fungal acne when someone cannot tolerate zinc pyrithione or ketoconazole. It smells bad but works.

• Piroctone Olamine

  An antifungal used in European and Asian dandruff products (sometimes alongside zinc pyrithione). It works much like ciclopirox, grabbing the metals the yeast needs to breathe. It is a common stand-in for zinc pyrithione in places where zinc pyrithione is restricted (notably after the EU reclassified it in 2022).

• MCT Oil (Caprylic/Capric Triglyceride)

  A lightweight oil whose fats are too short for the yeast to eat. Malassezia feeds on medium and longer fats (carbon chains of 11 to 24) and cannot make or use anything shorter, and MCT oil's fats are only 8 to 10 carbons long. That makes it the classic fungal-acne-safe oil. Use it anywhere a plant oil would otherwise feed the yeast.