"Fungal acne" isn't acne. The medical name is Malassezia folliculitis (older papers call it Pityrosporum folliculitis). It's an overgrowth of a yeast that normally lives on everyone's skin, inside the hair follicles. It looks enough like acne that people treat it with acne products for months, and it doesn't get better.
The reason it matters: the usual acne treatments don't touch it, and antibiotics, a common acne treatment, can make it worse. If your "acne" has been stubborn and itchy, it's worth ruling this out.
I'm not a doctor, and this is a condition that's worth getting confirmed. A GP or dermatologist can check a skin scraping under a microscope. What follows will help you recognise the pattern and know what to ask about.
What it looks like
The giveaways are the shape, the itch and the location.
- Lots of small bumps, all the same size. Usually 1 to 2mm, red or skin-coloured, sometimes with a tiny white top. Acne tends to be a mix: blackheads, whiteheads, bigger red spots and the odd deep one. Fungal acne looks uniform, like a rash of identical dots.
- It itches. Acne can be sore, but it rarely itches. In a review of 110 young people with confirmed Malassezia folliculitis, 65% of those asked reported itching.
- Forehead, hairline, chest, upper back and shoulders. The same review found it most often on the forehead extending into the hairline, and on the upper back.
- No blackheads. Comedones are an acne feature. A patch of bumps with no blackheads at all is a clue.
- It gets worse with heat and sweat. Summer, gym kit, a humid holiday, tight synthetic clothing.
You can have both. Fungal acne often sits alongside ordinary acne, which is part of why it's missed.
What triggers it
Malassezia yeast lives on almost everyone's skin and feeds on skin oils. Problems start when conditions let it overgrow inside the follicles:
- Antibiotics. This is the big one. In that same review, more than 75% of patients had recently been treated for acne with antibiotics. Antibiotics clear the bacteria that normally compete with the yeast, and the yeast fills the gap.
- Heat, sweat and humidity. Warm, damp skin under clothing is ideal for it.
- Occlusive clothing and products. Tight synthetic tops, heavy oils and thick creams that trap sweat.
- Steroid creams or tablets, and a weakened immune system.
- Oily skin. More oil, more food for the yeast.
The antibiotic link creates a familiar story: someone is prescribed antibiotics for acne, the acne improves, but a new crop of itchy little bumps appears on the forehead and chest that nothing seems to clear.
How to treat it
Antifungal washes
The most common first treatment is an antifungal shampoo used as a body and face wash. In the review above, ketoconazole shampoo was the most common treatment, and most patients improved or cleared.
- Ketoconazole 2% shampoo (Nizoral is the familiar brand, sold in UK pharmacies). Lather it onto the affected skin, leave it for three to five minutes, then rinse.
- Selenium sulfide or zinc pyrithione anti-dandruff shampoos are alternatives. Zinc pyrithione is in many supermarket dandruff shampoos.
A typical approach is daily use for one to two weeks, then once or twice a week to keep it from coming back. Avoid the area around your eyes, and stop if your skin gets irritated. Check the plan with a pharmacist or GP, especially if you're pregnant.
Prescription treatment
If washes don't clear it, or it's widespread, a GP can prescribe an antifungal cream or a short course of antifungal tablets. Danish evidence-based guidelines on Malassezia-related skin conditions note that for this condition, antifungal tablets are probably more effective than topical treatment alone, and that combining the two may work best. They also note that maintenance treatment is often needed to stop it coming back.
Stopping it coming back
It recurs often, because the yeast never fully leaves. What helps:
- Keep using the antifungal wash once or twice a week after it clears.
- Shower soon after exercise and change out of sweaty clothes.
- Wear looser, breathable fabrics in hot weather.
- Go easy on heavy oils and occlusive balms on affected areas.
What doesn't help
Standard acne treatments. Benzoyl peroxide and salicylic acid aren't aimed at yeast. They may help a little by reducing oil and clearing follicles, but they're not the fix. If you also have ordinary acne, keep treating that separately. See benzoyl peroxide and the minimal acne routine.
More antibiotics. Antibiotics treat bacteria, not yeast, and can make fungal acne worse. If you're on antibiotics for acne and developing itchy, uniform bumps, mention it to your prescriber.
Pimple patches. These bumps are too small and too numerous, and most have no head to absorb. Pimple patches are for individual whiteheads.
About "fungal acne safe" product lists
Online, you'll find long lists of "fungal acne safe" ingredients and apps that scan your products. They're based on lab work showing that Malassezia feeds on certain fatty acids and oils. That's real, but the lists go well beyond what's been tested on skin, and many ingredients are flagged on theory alone.
A reasonable middle ground: while you're treating a flare, use a light, oil-free moisturiser and avoid rich plant oils and balms on the affected areas. Squalane is generally considered a lower-risk oil. Don't throw out your whole routine based on an app score.
When to see a GP
- You're not sure whether it's fungal acne, ordinary acne, or something else. Several conditions look similar, and a simple skin scraping can confirm it.
- An antifungal wash hasn't helped after two to three weeks.
- It's spreading, painful, or keeps coming back.
- You have a weakened immune system.
References
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. (https://pubmed.ncbi.nlm.nih.gov/29138059/)
Hald M, Arendrup MC, Svejgaard EL, et al. Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. Acta Derm Venereol. 2015;95(1):12-19. (https://pubmed.ncbi.nlm.nih.gov/24556907/)
FAQs
How do I know if I have fungal acne or normal acne?
Fungal acne is usually itchy, made of small bumps that are all the same size, sits on the forehead, hairline, chest and upper back, and has no blackheads. Ordinary acne is a mix of spot types and rarely itches. A GP can confirm it with a skin scraping.
What clears fungal acne fastest?
An antifungal wash such as ketoconazole 2% shampoo, left on the skin for a few minutes daily, is the usual first step. Stubborn cases may need prescription antifungal tablets.
Can antibiotics cause fungal acne?
They can trigger it. Antibiotics reduce the bacteria that keep the yeast in check. Most patients in one large review had recently taken antibiotics for acne.
Will fungal acne go away on its own?
Sometimes it settles when the trigger goes, for example cooler weather or finishing antibiotics, but it often lingers or recurs without antifungal treatment.
Can I use Head & Shoulders for fungal acne?
Zinc pyrithione shampoos like Head & Shoulders are sometimes used as a wash for mild cases or for maintenance. Ketoconazole is the more commonly used treatment.