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The Acne that isn't Acne

By: Risa Caldoza, MD, FPAMS, FPAPSHPI, FPAAAMIThe Acne that isn't Acne

Pimples, zits, breakouts…must be acne, or is it? Funny thing is, you’ve used the last drop of your acne-fighting arsenal and the red bumps still stubbornly sit all over your face, back, and chest, itchy as ever. Ever heard the phrase “If it looks like a duck and swims like a duck, it probably is a duck?" Well, in this case, more likely a goose: a fungal infection called Malassezia folliculitis (MF), a common but usually misdiagnosed (even by the trained eye of your derma) affliction. It looks and feels like acne vulgaris but is different from its distinct treatment. The term fungal acne is quite misleading (no such thing in medical speak) because the run-of-the-mill acne is caused by bacteria.

It was only in 1968 when the specific disease was recognized.  Affecting people of all ages (yes, even infants) and all races but more common in temperate countries. Up to 16% of Filipinos usually teens and young adults are affected.

MF crops up as uniformly-sized small itchy pinkish pus-filled bumps called papules and pustules on the face (chin and sides of the face), upper back, arms, chest, and neck. When extracted, the goo is white or yellow. This dome-shaped lesion heals with a brown crust. It often comes in flares depending on activities such as intense exercise or outdoor work, current treatment regimens especially use of oral antibiotics and immunosuppression. There are some reports of MF because of sun exposure, obesity, pregnancy, steroid use, birth control pills, Down syndrome, multiple trauma, and stress.

In a local study, MF co-existed with acne vulgaris in almost six of 10 Filipino patients. If you have MF, you might also have other signs of fungal overgrowth such as dandruff, pityriasis versicolor or an-an, psoriasis, atopic dermatitis, and seborrheic dermatitis.

MF isn’t life-threatening but it can be uncomfortable and embarrassing. However, severe infections may lead to permanent hair loss and scarring.

Spores of Malassez

Say hello to permanent residents intimately and harmlessly holding court in your skin from head to toe. In certain conditions, this peaceful and balanced community of 500 bacterial species and 80 kinds of fungi may cause or aggravate the disease.

In the late 19th century, French scientist Louis-Charles Malassez first described Pityrosporum ovale, an oval spore-forming single-celled fungus, a yeast. Confusing names such as Bacillus of Unna, Balloon Bacillus of Hodara, and Bottle Bacillus of Sabouraud cropped up. MF was called Pityrosporum folliculitis before the 1980s because of the culprit. But with lumping of Pityrosporum species into the genus Malassezia, it’s now called MF.

Malassezia yeast (yes, yeast to make bread rise or brew beer but a different type) live in the skins’ topmost layer, in areas rich in sebum or oil like bulbs of hair follicles, the small pocket where hair sprouts. Our skin’s sebaceous glands churn fats to lubricate and waterproof the skin, and these yeasts munch on these fats for energy.

Ninety percent of people host nine of the 14 Malassezia species as normal skin microbiome without showing any signs of skin disease. When the skin’s flora is thrown out of whack, a large number of Malassezia yeasts can invade hair follicles, plugging it to cause MF’s acne-like bumps.

Of tablets and potions

Doctors confirm MF based on what they see clinically and the response to therapy. But just to make sure, they may ask for additional tests and grab a skin sample from pustules to test under the microscope, easy and painless. They may do shave or punch biopsies, too.

These misbehaving beasts are vital parts of the microbiota and all should not be killed, just controlled. MF usually responds well to oral antifungal medications such as ketoconazole, itraconazole or fluconazole. They may carry side effects such as nausea, vomiting, diarrhea, stomachache, and toxicity to the liver. Additional topical therapy, such as ketoconazole lotion and shampoo, may be given for maintenance.

Prevention is still the best cure. Avoiding factors that trigger MF is a priority. Stopping the use of oral antibiotics or steroids may improve MF without any particular treatment. Keeping the skin dry, avoiding tight workout clothes for the gym rat, and using the right skincare products may help attain that flawless skin.

If you suspect you’re dealing with fungal acne, hightail it to your doctor. After all, MF is not an invasion of a fun guy. 

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