Halloween may have come and gone, but here’s a spooky story that sounds like a nightly campfire is worth it. [Turns on flashlight and holds it under chin] Imagine: you wake up one morning with large, itchy pustules on your face that all look the same and won’t go away. You visit one dermatologist after another who attacks the bumps with everything from antibiotics to Accutane – yet you get no rest. Something strange happens, but the experts say it is just an outbreak.
The villain of the plot is fungal acne. It can wreak havoc on smooth skin, but since it often appears alongside normal acne, even well-trained dermatologists often miss the diagnosis. It also looks suspiciously like steroidal acne, which can happen when you take an oral corticosteroid to treat things like allergies or eczema. Plus, fungal acne on the face is so rare that it is at the bottom of the list of suspected outbreaks. It happened a few years ago with Emily Ferber, who for a solid week was convinced she had a fungus outbreak. (She didn’t.) But last week the urban legend of fungal acne was confirmed by a person I actually knew: my friend Christina, who was properly diagnosed and lived to tell the story. “I’ve had acne since I hit puberty, but it looked like what I know now is fungal acne when I was 15,” Christina told me on the phone. “I kept putting spot treatments on my forehead and nothing worked.” While the fungus went undetected, Christina’s dermatologists tried everything – and she didn’t find a solution until five years later. “I was definitely told that I had fungal acne on certain parts of my face,” she explained, “and they finally gave me stuff that got rid of it.”
Fungal acne, or Malassezia folliculitis, occurs when there is too much yeast on your skin and your pores become inflamed. To be clear, it’s not weird or gross – Malassezia yeast is just one character in the diverse cast of microscopic organisms that make up your skin’s microbiome. “It is completely normal for this type of yeast to live on the skin,” says dermatologist Dr. Hadley King, “but certain drugs or environmental factors can upset the balance.” Fungal acne on the face is less common as it is mostly triggered by tight, non-breathable clothing that creates the kind of humid environment yeast loves. If you have fungal acne on your face, Dr. King that it is most likely to pop up on the upper forehead. However, the humidity under protective face masks can also contribute to fungal acne further down the face. Other potentially contributing factors include warm climates, humidity, antibiotics, and chronic diseases that affect your immune system. You may also be genetically predisposed to yeast overgrowth – just as some people are predisposed to more common vaginal yeast infections caused by another yeast called Candida.
Fortunately, when you have fungal acne, it’s easier to treat than diagnose. “Using an antifungal with zinc pyrithione or selenium sulfide in place of your usual detergent once a week can help,” says Dr. King. Christina had success with ketoconazole, a prescription antifungal drug that her dermatologist gave her after she received the correct diagnosis. And while it may sound strange, anti-fungal ingredients are also found in over-the-counter anti-dandruff shampoos for drugstores – selenium sulfide is in selsun blue, and Head and Shoulders has zinc pyrithione. They work because dandruff is caused by the same yeast. If you’re not ready to apply shampoo directly to your face, Vanicream’s Z-Bar is another option for zinc pyrithione. A milder antifungal agent is mandelic acid, which is also a gentle exfoliant. Acid salicylic acid can also be helpful, although it is not a direct antifungal. “Salicylic acid can help remove dead skin cells and oils that yeast feed on,” she explains. In other words, when the all-you-can-eat buffet closes the yeast heads.
If there is a chance something is wrong, you should see a dermatologist to confirm the diagnosis. Because first of all you could have been wrong! Second, your derm has a slightly larger tool kit to deal with fungal acne. “A dermatologist can prescribe an oral antifungal that is often faster to act,” says Dr. King. You can also combine an antifungal with something like Retin-A to fade dark spots and help you develop strategies on how to soothe non-fungal acne as well. (The two are often partners in crime.)
Most scary stories don’t end with a happy ending, but this one does. “There is often a trigger for fungal acne, like taking an oral antibiotic that disrupts the balance of the microbiome or wearing sweaty gym clothes,” says Dr. King. And if you can figure out the trigger and avoid it, you probably won’t have to deal with fungal acne recurrence anytime soon. No sequel required that is worse than the original.
Photo via ITG