It’s hard enough to deal with regular acne in general. However, it can be even more upsetting when acne doesn’t not behave like it normally does. Seemingly and out of nowhere, breakouts persist despite strict skincare routines, flare-ups come up in response to products that are supposed to help or spots appear suddenly in places that never previously caused trouble. The assumption is usually that the acne is “stubborn” or has become “resistant.” When actually, the breakouts might not be from your regular acne at all and instead a completely different condition! All hope is not lost though. Rather than throwing out your regular acne treatments, it’s worth pausing and considering whether you might actually have fungal acne. In this article, we explore the difference between regular acne vs fungal acne. We’ll review how to tell them apart as well as the best way to prevent and treat fungal acne.
What is Fungal Acne?
First of all, the term fungal acne whilst widely used, is technically not accurate. This is because it implies that the condition is a subtype of acne caused by fungus. The more accurate term for this condition is actually Malassezia folliculitis which is an inflammatory disorder that affects the skin follicles driven by yeast over growth on the skin. It is very distinct from acne pathology but due to it’s similar appearance to acne and easier name, the term fungal acne persists. Malassezia is yeast that normally lives on human skin. Under certain conditions like heat, pore clogging, increased lipids or skin barrier damage, it can over grow within the hair follicles. This triggers an inflammatory immune response which leads to breakouts that look similar to acne.
However, despite their appearances acne and Malassezia folliculitis respond to different treatments. Approaches that calm acne can sometimes worsen yeast-driven breakouts. Similarly, measures that may control fungal acne often fail to treat regular acne.
What is Acne Vulgaris?
Acne vulgaris (to give it it’s proper name) is a chronic skin condition of the pilosebaceous unit (this includes the oil glands and hair follicle). It develops through a combination of increased sebum (oil) production due to androgen hormone sensitivity, abnormal keratinisation leading to pore blockage and over growth of acne causing bacteria. This process results in microcomedone formation, pimples and inflammation. At its simplest acne presents as whiteheads and blackheads but in its more severe there maybe pustules, cysts and even nodules. Acne usually responds to conventional treatments like retinoids, antibiotics and hormonal therapies. Effective treatment requires suppressing the immediate inflammation and changing the underlying drivers to achieve long term control.
How Does Fungal acne Differ from Regular Acne?
Both acne vulgaris and Malassezia folliculitis can look similar at first glance. Both can present as small inflammatory spots, affect the face and body and flare with heat or sweating. This surface overlap is why misdiagnosis is so common. However, there are very clear and identifiable differences between fungal acne vs acne vulgaris which include:
- Monomorphic lesion pattern: Fungal acne presents with spots that are uniform in size and shape. Acne vulgaris is polymorphic meaning that the spots can be variable in size and shape. It may present with open or closes comedones, papules, pustules or even cysts. Often there is more than one type of lesion in acne vulgaris.
- Absence of comedones: Unlike in regular acne, yeast-driven breakouts do not produce blackheads or whiteheads.
- Pruritis: Itching is very common in fungal acne and it often worsens with heat or sweating. Acne lesions may be tender or sore, but itch is not usually a typical feature.
- Sudden Clustered Onset: Malassezia-related breakouts often appear rapidly and in dense clusters. Acne typically evolves more gradually, with lesions at different stages of development.
- Characteristic Distribution: Fungal acne most commonly affects the upper back, chest, shoulders, forehead and sometimes the neck or jawline. Facial involvement often occurs alongside disease on the body. Acne is most common on the face and neck but can also occur on the chest or back. It rarely occurs in other parts of the body.
- Sensitivity to Skincare: Rich creams, facial oils and occlusive products frequently worsen fungal acne because they increase lipid availability within the follicle. Whilst here are some comedogenic products that trigger acne vulgaris, it is not as sensitive to moisturising products as fungal acne is.
- Poor Response to Acne Treatments: Retinoids like tretinoin which are the cornerstone of acne vulgaris treatment, may irritate the skin without improving fungal acne. Some antibiotics may produce short-term improvement by changing microbial balance and inflammation, but usually this is modest and relapse is common.
- Flares Linked to Environment: Heat, sweating, exercise and tight or occlusive clothing often trigger or worsen fungal acne breakouts. These conditions create an environment that favours yeast growth.
Why Does the Difference Between Acne vs Fungal Acne Matter?
Treating acne vulgaris and fungal acne in the same way tends to worsen the breakouts or make them endure longer. This is because mistaking yeast-driven breakouts for fungal acne gives the impression that the treatments have failed it became resistant, As such there’s tendency to escalate by using stronger actives, antibiotics and even completely changing the skincare routine. This can further disrupt the skin barrier and alter the conditions that favour Malassezia yeast over growth rather than suppressing it. The reverse is also true. Assuming all persistent acne is fungal can lead to mismanagement which prolongs breakouts and increases risk of post acne marks and scars. This is why it is vital to distinguish between fungal acne vs regular acne.
That being said, it is also worth stating that acne and fungal acne can coexist. This is particularly common in adults with acne vulgaris who also have seborrhoeic dermatitis. In these cases, treatment needs to address both conditions at the same time without irritating the skin.
How to Prevent and Treat Fungal Acne vs Acne Vulgaris?
Effective management depends on knowing between whether you have acne vulgaris vs fungal acne (or both). The aim for both should be to treat acute flare-ups, prevent recurrent and ensure long-term control. Below are some of the key measures to treat and prevent these conditions:
- Acne Treatment: This requires modifying behaviour of the skin over time. Retinoids such as tretinoin and adapalene normalise keratinisation which reduces pore clogging and microcomedone formation. Ingredients like azelaic acid and benzoyl peroxide can help control inflammation and kill acne causing bacteria. In hormonally driven adult acne, medications like spironolactone and winlevi block androgen actions at the oil gland to reduce sebum production. Lastly, antibiotics can provide short term suppression of active inflammation to help clear flare-ups.
- Fungal Acne Treatment: Malassezia folliculitis needs reduction of yeast growth within the follicles. This requires anti-microbials like ketoconazole and removal of conditions that favour yeast growth such as excess lipid availability and heat. Standard acne treatments are may worsen irritation without improving the breakouts. However, products like azelaic acid and benzoyl peroxide do have some value as the possess anti-microbial and anti-inflammatory actions.
- Treatments for Both: Where you have both conditions, treating only one process leads to partial response. You will need to use acne-modifying treatments alongside acute strategies that reduce the yeast over growth and inflammation. Just ensure that the treatments are not so aggressive they damage the skin barrier. Also avoid over doing “barrier repair” that you end up feeding the yeast or under treating the acne vulgaris.
- Prevention & Maintenance: Preventing acne relapse relies on continued use of disease-modifying treatments like retinoids, exfoliating acids and hormone therapies where necessary. Preventing fungal acne recurrence depends on preventing yeast overgrowth. This means avoiding things that make the perfect environment for it to grow such as heat, sweating and lipid-rich skincare.
Persistent or abnormal breakouts should trigger reassessment rather than escalation of current acne treatments as there may be due to fungal acne. Distinguishing between regular acne vs fungal acne matters because both require different approaches to treat and prevent them. Additionally, they can both co-exist which requires an even more thoughtful approach.
At City Skin Clinic, we are beyond passionate about personalised skincare. Our virtual skin clinic offers safe and effective custom skin treatments. Where appropriate our doctors use ingredients such as Tretinoin, Hydroquinone, Azelaic acid, Clindamycin and Spironolactone to treat skin conditions like acne, hyperpigmentation, melasma and skin ageing. Start your online consultation today. The journey towards great skin starts here.
This article is intended for general informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical provider for any medical concerns or questions you might have.
