What if you’ve been fighting acne for years, using benzoyl peroxide religiously, and achieved no difference?
What if you’ve explored every natural acne treatment yet discovered, and failed to notice the slightest improvement? You might have thrown in the towel, believing that your genetics are unbeatable.
But there’s another possibility. Maybe you weren’t fighting acne after all. Maybe you were fighting pityrosporem follucilitis, a master of disguise which can look all too similar to traditional acne.
What is pityrosporum folliculitis?
Pityrosporum folliculitis, or malassezia folliculitis, is a disease of inflamed, red, itchy skin with numerous tiny spots. It’s caused by a yeast that lives in human skin called malassezia, formerly known as pityrosporum, whose human subspecies is called malassezia furfur.
Malassezia is a commensal yeast, meaning that it’s a naturally occurring microorganism found in almost all healthy human beings. The species is specially adapted to live on skin. Its full beneficial roles are unknown, but like p.acnes bacteria, it consumes fats and oils for its energy, and hence prevents clogged pores. Malassezia helps to curtail more infectious microorganisms as well.
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Think about fungi, and you think about infection, but a healthy skin microbiome consists of 1-22% fungi, and almost all of that is malassezia. At low levels, the immune system ignores malassezia, and no irritation occurs…
…but like the equally natural p.acnes bacteria, malassezia levels can overgrow. Like p.acnes again, certain people have a lower genetic tolerance for malassezia.
In both circumstances, malassezia triggers an immune system response, and generates excessive toxic metabolites. It creates its own unique skin disease – pityrosporum folliculitis. A disease characterised by extreme itchiness, tiny red to white spots, and a red and inflamed appearance. You can see pictures of the disease at this link. It differs not just from acne, but also rosacea, dermatitis, and psoriasis.
Differences between acne and pityrosporum folliculitis
At a casual glance, acne and pitysporum folliculitis look like the same disease. From five metres away, it’s very hard to tell the difference. But once you understand the signs to look for, spotting the difference becomes easy:
The size – the size of acne varies massively, from tiny whiteheads to raging battlefields centimetres wide. Meanwhile, almost all pityrosporum folliculitis is small and hard, and consistently so.
The location – it’s often stated that pityrosporum folliculitis rarely occurs on the face, but this is completely false. One study examined 49 patients and noted the most commonly affected areas: the face (57.1%), the back (53%), the arms (38.8%), the chest (36.7%), and the neck (18.3%). 71.4% of those patients had the disease in more than one place.
Where pityrosporum folliculitis differs is in the higher amount of body acne. While acne vulgaris is strongly connected to oil, pityrosporum folliculitis has an even tighter link. Hence, greasy parts of the body are most vulnerable, including the neck, back, chest, shoulders and scalp.
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The facial distribution is also different: the chin and sides of the face are most commonly affected with PS, whereas acne specialises in the cheeks.
The itchiness – acne itself rarely itches, but pityrosporum folliculitis bumps are notorious for itchiness. Both anecdotal stories and studies have reported this. A person with acne can have itchy skin, but because of dryness and flakiness, or bonus irritation – not the acne itself.
The spots – this is the most obvious visible way to differentiate the two. With acne, you have a variety of whiteheads, blackheads, cysts and pimples. With pityrosporum foliculitis, you have consistent hard, red to white bumps. Many bumps look like whiteheads, but don’t behave like them, releasing a hard grainy whiteness instead of an explosion.
Pityrosporum folliculitis bumps also have a diffuse redness that normal acne lacks, a redness of the surrounding tissue that spreads away from the spot and contributes to a “rashy” appearance. Normal acne can have this quality, but only when irritated, like after a manic, irresistible popping.
A shared characteristic is that teenagers are the main victims, as both diseases are caused by high oil production.
What are the causes of pityrosporum folliculitis?
Malassezia overgrowth isn’t close to fully understood yet. But like acne itself, oily skin is a big factor, because malassezia yeasts consume it for their fuel. Therefore, anything that causes oily skin like elevated DHT, insulin or vitamin A deficiencies could be involved.
Heavy abuse of antibiotics is also a factor. In the world of microorganisms, yeasts and bacteria are constantly competing with each other. A deficiency in bacteria caused by tetracycline and its cousins could give malassezia an opportunity to take over, upsetting the natural balance. Benzoyl peroxide abuse could also trigger this chain of events.
Type 2 diabetes has been linked to malassezia overgrowth. Malassezia is particularly abundant in hot and humid climates, conditions this yeast loves for expanding beyond its natural territory.
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Malassezia can also trigger a more benign condition called Pityriasis versicolor, characterised by pale and depigmented patches of skin. A much more famous symptom of malassezia is dandruff. If you’re a man or woman with greasy hair genetics, malassezia yeasts can find a delightfully comfortable home on your scalp. If they multiply too far, they can consume the oils to such an extent that moisture evaporates and skin cells fall apart.
Hence, malassezia causes dandruff, a dry and flaky scalp, joining other causes like zinc deficiency and poor protein consumption. This is connected to pityrosporum folliculitis as well, because flakiness can be another symptom.
The implications
What if you secretly have pityrosporum folliculitis, but believe that you have acne and strategize accordingly? Firstly, eating more antioxidants will be ineffective, because as far as we know, squalene peroxide has no involvement.
Secondly, many of the great strategies I recommend are not proven for pityrosporum folliculitis. Zinc, selenium, vitamin E, green tea, and NAC are all proven to reduce acne, but could achieve nothing if your condition is secretly PS, leaving you confused and despondent.
This is also true for conditions that increase acne. Stress is a proven cause, as are sunflower seeds; will rejecting them be effective for pityrosporum foliculitis?
The biggest problem is the war on p.acnes bacteria, which is an excellent idea to prevent acne, but the exact opposite here. Benzoyl peroxide and antibiotics are the staple medications for acne. Despite their side effects, they work in the short term, but crushing bacteria will simply cement the dominance of the malassezia yeast.
If you secretly have pityrosporum folliculitis and use pharmaceutical remedies, you could end up blasting away at p.acnes harder and harder, only to watch your skin get messier and messier. In time, you will probably disregard everything anybody tells you and simply give up. That’s why it is vital to establish what your skin condition really is.
How do you treat it?
The prescribed anti-fungal medication for pityrosporum folliculitis is ketoconazole. You can take ketoconazole as an oral medication, but a ketoconazole-containing shampoo called Nizoral is a favourite among the yeast-infected.
Your orders are to apply Nizoral while in the shower, leave it to absorb for 5 minutes, and wash it off promptly. Ketoconazole inhibits malassezia very effectively, and its effects linger on the skin for 3 days after application. If you use ketoconazole, once every 3 days is enough.
But oral ketoconazole was banned in many countries for causing liver damage. While topical application is safer, it’s still known to irritate the skin. It’s also an indiscriminate, napalm-like yeast killer. After all, it’s designed to kill a wide range of fungi, and while its damage isn’t proven, the delicate balance of the skin’s ecosystem should always be approached wisely. Some of the scenarios discussed earlier illustrate this…
Alternative treatments
…which is why natural treatments should never be ignored. Not just because they are natural, but because they are less discriminate, under-investigated and potentially highly effective.
Tea tree oil was the first natural solution to be discovered; this study tested it against 22 species of malassezia furfur and 32 species of the yeast candida. Tea tree oil was very active against malassezia in particular, requiring low concentrations.
Two unexpected remedies were garlic and onions, found in this study to be promising against 25 different strains of malassezia. This giant review analysed 108 different essential oils, and garlic was reaffirmed as an effective malassezia killer.
Interestingly, lime oil was the strongest essential oil by a big margin, but I strongly recommend against lime oil due to its photosensitising properties, unless you’re living in a hut in the middle of a snowy winter. The promising oils revealed in this study also included thyme oil, oregano oil, caraway seed oil, pimento seed oil, and catnip oil.
Just as importantly, it revealed the top quality acne treatments which had no effect: lavender oil, peppermint oil, rose water, and rosemary extract. Weirdly, tea tree oil had no effect in this study; perhaps it was a dodgy batch, but that’s a mark against it.
Perhaps the most surprising remedy is cinnamon. In this study, cinnamon was tested alongside thyme oil against two yeasts: candida and malassezia. Cinnamon inhibited malassezia strongly, while the thyme oil was effective, but weaker. Cinnamic acid and cinnamaldehyde were identified as the miracle compounds.
Interestingly, cinnamon didn’t inhibit candida effectively, whereas thyme oil did. Cinnamon only has targeted powers against malaezzia, rather than blasting all yeasts into oblivion with brute force.
Identify whether you have pityrosporum folliculitis, and apply a mixture of these topical treatments daily. A mixture of cinnamon and thyme oil may succeed. You could also embrace laziness, and combine cinnamon powder with cinnamon essential oil. Two other popular treatments are zinc pyrithione and selenium sulfide.
More importantly, you need to prevent malassezia from ever dominating your skin in the first place.
It’s commonly recommended that pityrosporum folliculitis patients avoid natural oils, to avoid feeding the yeast. But is it smart to obey this forever? You lose moisturising benefits, collagen-increasing benefits, and natural sunscreen properties. If you hate skincare in general, do you want to be stuck applying cinnamon oil forever?
To cure pityrosporum foliculitis, you initially need to curtail the existing infection, either with ketoconazole or essential oils like thyme and cinnamon. We mostly recommend against pharmaceutical remedies on this website, particularly topical antibiotics, but topical ketoconazole (never oral!) is one where a short, sharp shock might do the trick.
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Once the overgrowth is eradicated, you need to prevent the oily skin and feast of fatty energy that allows malassezia to thrive. The same instructions for acne will work: reducing your insulin levels by eating less carbohydrates, controlling your DHT if you’re a woman, correcting your vitamin A, and using certain topical treatments like green tea.
Secondly, curtailing chronic inflammation is also vital for pityrosporum folliculitis. Like with acne, it’s the overactive immune system assault on the microorganism which creates the small red spots. Here, you can use the same strategies we constantly recommend for acne: getting zinc, eating omega 3s from fish, eating blueberries, avoiding omega 6s from vegetable oils, etc.
Conclusion
I would look in the mirror right now and analyse your skin. You don’t want to waste months or years treating the wrong disease. If you do bear the ominous signs, consider the failed treatments you’ve used over the years, and consider whether their failure makes sense.
You might be annoyed or even angry with yourself, but look at it this way: you now have a precise explanation of why you failed. You’re no longer lost in the wilderness; you have a way forward.
Luckily, the differences are obvious. An interesting fact is that pityrosporum folliculitis and acne vulgaris rarely coincide with each other. It’s been confirmed by Koreans that overgrowths of bad p.acnes strains and malassezia rarely occur in the same skin pores. Whether this is caused by normal yeast and bacterial competition or a specific competition between these two microorganisms is unknown.
Regardless, this means that if you do have some easy-to-pop whiteheads, a clear sign of acne, it’s unlikely that pityrosporum folliculitis will be bubbling away under the surface as well.
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Thanks for reading!