Pityrosporum (Malassezia) Folliculitis Treatment: How to Kick Fungal Acne’s Ass
UPDATE 6/10/17: If this blog post has helped you out, and/or you want to check out sample routines that are safe for malassezia — click that link! Back to the original post….
First and foremost, my sincerest apologies for taking so long to finally publish this. I assure you I’ve read everyone’s messages, and I’m so sorry if I haven’t gotten back to you.
This article took an unbelievable amount of research. A lot more than I expected. For reference, check out what my browser looked like on any given day I was writing this.
It’s no secret that treating pityrosporum folliculitis is complicated business. I mean seriously, a recent medical paper in 2014 was literally titled “Malassezia infections: A medical conundrum,” because of how problematic and complex these diseases are becoming.
BUT…. today you will be learning absolutely everything you need to know about how to DESTROY this thing once and for all.
This blogpost is ~13,000 words long, or about 50 pages if this were a book. Take your time with it. You will learn a lot, and I’ve tried to answer every possible question you might have.
With that said, here’s a list of everything will we be talking about today.
Table of Contents
- 1 What is Pityrosporum Folliculitis?
- 2 Skin Conditions Associated With Malassezia.
- 3 Pityrosporum Folliculitis Causes.
- 4 Pityrosporum folliculitis Symptoms. How to Tell if You Have it.
- 5 What to Avoid if You have Malassezia Folliculitis.
- 5.1 Fatty acids and Oils.
- 5.2 Esters.
- 5.3 Polysorbates
- 5.4 Fatty Alcohols
- 5.5 Yeast Ferments
- 5.6 Cholesterol
- 5.7 Squalene
- 5.8 Phytosphingosine
- 5.9 Additional Notes (Other)
- 5.10 Summary.
- 6 Oils That Won’t Aggravate Malassezia.
- 7 Best Products for Pityrosporum Folliculitis.
- 8 Pityrosporum Folliculitis Treatment.
- 9 Pityrosporum Folliculitis Natural Treatment Options.
- 10 Final Words.
What is Pityrosporum Folliculitis?
A f*cking a**hole that’s what! Alright, but seriously…..
Pityrosporum Folliculitis a.k.a malassezia folliculitis is an acne-like breakout often accompanied by itchiness that flares most in areas with a lot of sebaceous activity. (1) This includes the t-zone area of face (especially forehead), shoulders, chest, and back.
It’s frequently misdiagnosed as “normal” acne, which is extremely frustrating because this often leads to unnecessary and prolonged treatment with medications like antibiotics that only further exacerbate the condition. (2, 3)
Like a pair of researchers put it,
“Malassezia (Pityrosporum) folliculitis is a fungal acneiform condition commonly misdiagnosed as acne vulgaris. Although often associated with common acne, this condition may persist for years without complete resolution with typical acne medications.” (4)
And by typical acne medications, they’re even referring to Accutane a.k.a. the most powerful prescription drug available today. Yup, can you believe that? This damn thing is so stubborn that there have been several cases of relapse after courses of accutane. (5)
It distinguishes itself from traditional acne in that it’s fungus not bacteria causing the breakouts.
Particularly, a little son a b*tch called malassezia. This is a genus of fungi that is an ordinary part of the skin’s microbiome (i.e. the healthy bacteria and yeast that live on skin), and is found in an estimated 92% of all people,
but for poorly understood reasons becomes pathogenic for select individuals. (6, 7, 8)
It’s a polymorphic, lipophilic microorganism meaning it thrives on the lipid composition of sebum. (9) Or more simply put, it grows in the presence of human skin oil.
“Human sebum is the lipid source these yeasts thrive on because it is a complex mixture of lipids. It contains triglycerides, fatty acids, wax esters, sterol esters, cholesterol, cholesterol esters, and squalene. Sebum is utilized by breaking down triglycerides and esters, into diglycerides, monoglycerides, and free fatty acids.” (10)
This fungi starts causing skin problems when it transitions from the yeast to mycelial phase. If you have no idea what that means, here’s a quick refresher:
Fungi like malassezia have something called a hypha (hyphae for plural), which is collectively known as the mycelium. This is the part of the organism that allows it to growth via asexual reproduction. It does this by absorbing nutrients from its environment. In the case of malassezia, that’s facilitated by the fatty acids in your skin’s oil (sebum).
If you’re confused, here are those terms again.
- Hyphae = part of fungus that allows it to grow by eating stuff.
- Mycelium = a group of hyphae.
Got it? Cool. Will will use these terms later so keep them in mind.
Different Species of Malassezia
Within this family of fungi, there are 14 main lipophilic species that have been isolated from human and animal skin. They are….
- M. caprae
- M. cuniculi
- M. dermatis
- M. equina
- M. furfur (combination of P. ovale and P. orbiculare)
- M. globosa
- M. japonica
- M. nana
- M. obtusa
- M. pachydermatis
- M. restricta
- M. slooffiae
- M. sympodialis
Different species can cause different skin problems, which leads to our section….
Skin Conditions Associated With Malassezia.
- Atopic dermatitis a.ka. eczema (associated with M. globosa, M. furfur, M. sympodialis, and M. restricta). [12, 13, 14, 15, 16]
- Dandruff (probably caused my M. globosa). 
- Psoriasis (associated with M. furfur, M.restricta, and M. globosa). [18, 19, 20]
- Seborrheic dermatitis (most commonly caused by M. furfur, M. globosa, M. restricta, though M. sympodialis, M. obtuse, M. slooffiae, and M. yamatoensis have been implicated). [21, 22, 23]
- Tinea versicolor a.k.a. pityriasis versicolor (caused by M. globosa, M. sympodialis, and M. furfur). [24, 25]
And of course…..
Because there is a lot of overlap between all these skin conditions, the treatment guidelines I will list in this blog post for pityrosporum folliculitis can be applied to treat many of the other diseases with success.
Fun fact #1: M. furfur is a combination of pityrosporum orbiculare and pityrosporum ovale.
Perhaps you noticed that M. globosa and M. furfur are found in all of the skin conditions above. You’ll want to remember these asswads. For many of us, eradicating these suckers will do the trick and cure us of our skin woes.
NOTE: I say “many of us” because that’s not always true. The pathology of malassezia is very complicated, and varies tremendously according to geographical location and ethnicity. (30)
For example, Iranians with seborrheic dermatitis have very high levels of M. globosa and almost no M. restricta, and M. sympodialis, whereas South Koreans with seborrheic dermatitis show the opposite — predominantly high levels of M. restricta, and M. sympodialis, and a lot less M. globosa.
The differences in what species causes the problem probably has to do with climate. (31) We will discuss this more later.
Pityrosporum Folliculitis Causes.
Like I mentioned above, pityrosporum folliculitis is poorly understood but there are a few predisposing factors that may cause it to flair. Let’s go over them.
There are higher incidences of malassezia folliculitis among patients with diabetes, HIV, Hodgkin’s disease, organ or bone marrow transplant recipients, or those with nutritional disorders, neurotransmitter abnormalities, and immunologic deficiencies. (32, 33, 34)
Another fairly common way pathogenic malassezia is brought about is through antibiotics! (35) Indeed, prolonged use of broad-spectrum antibiotics (e.g. tetracyclines) can alter the gut microbiota and skin flora causing malassezia to proliferate. (35)
This is something that is especially frustrating because:
- As we mentioned earlier, malassezia folliculitis is often misdiagnosed as acne.
- Doctors are quick to prescribe antibiotics in the cases of acne despite their subpar success rate and potential side effects like fungal superinfection, gastrointestinal intolerance, and oxidative stress. (36, 37)
All the more reason you should inoculate yourself with high quality probiotics following your antibiotic use.
We will discuss this in more detail in the “things to avoid” section, but in short many skincare products, high humidity, hot weather, sweat, and excessive occlusion can cause malassezia skin conditions to get worse.
Fun fact #2: pityrosporum folliculitis coexists in 56% of acne patients in the Philippines, which is probably has to do with the hot and humid environment over there. (42)
The Philippines is also number 2, in terms of region that searches the word “acne” the most on google. :'( Stay strong my Filipino brothers and sisters!
Pityrosporum folliculitis Symptoms. How to Tell if You Have it.
Have you tried many acne medications with no success? Are you an adult wondering why the hell you still have acne? Do most skincare products cause you to breakout? DO YOU EVEN REMEMBER WHAT IT FEELS LIKE TO BE PIMPLE-FREE?
(I feel like I’m doing an awful infomercial here….)
If you answered yes to any of these questions CALL 1-800-555 — okay, I’m kidding. :p But seriously, those are all a couple of warning signs. Let’s break them down.
Firstly, if you’re an adult with acne this should give you food for thought. I mean, one of the first papers ever published on this subject (1985) was literally called, “pityrosporum folliculitis: a common disease of the young and middle-aged.” As in teen-young and adults.
More recent papers have confirmed this is quite common among young adults (20s and 30s), (43) and one study found that 30 year olds had significantly more species of malassezia than any other age group over 40. (44)
The more obvious signs that you have it include acne-like bumps on the face (especially t-zone), back, chest, and shoulders which are sometimes accompanied by itching.
These “pimples” are incredibly stubborn and don’t respond to typical acne medications. They’re usually in the form of papules and pustules (i.e. no cystic acne), and when extracted the material is white/yellow.
Another tale-tell sign is if you breakout out from literally EVERYTHING. Creams, moisturizers, toners — it doesn’t matter they’re all the same: a oneway trip down breakout boulevard. And don’t even get me started on sunscreens….
And that’s really it. Besides a couple warning signs and looking at photos on google and comparing things visually, there’s only so much you can do at home unfortunately. :/
The best way to know for sure is by getting a proper diagnoses. This is usually done through a shave biopsy in one of the areas where it flares most (i.e. upper back, chest, shoulders, scalp, or t-zone area of the face). (45)
However, even this has limitations and might come out negative because it reveals what yeast are on the surface of skin (i.e. stratum corneum) rather than within the follicle where it’s most present. If you can, tell your doctor to extract a pustule with a comedone extractor and examine its contents under a microscope.
What to Avoid if You have Malassezia Folliculitis.
And this is where things get depressing because there’s a lot we need to steer clear of…. Let’s discuss. -_-
Fatty acids and Oils.
Source: Wilde, P. F., and P. S. Stewart. 1968. “A study of the fatty acid metabolism of the yeast Pityrosporum ovale.” Biochem. J. 108: 225–231.
This means that most skincare products available today (I’d say over 95% of them) are problematic because they almost always contain a variation of a fatty acid that will feed malassezia.
Keep in mind that oils also contain fatty acids, usually in the from of triglycerides. Unfortunately, malassezia is quite the practical fella and has enzymes (lipases and phospholipases) that can hydrolyze triglycerides into free fatty acids. (49) In other words, it can break down the fatty acids in oils and use them to grow as well. This has been demonstrated in many studies.
Let me say that again because it bares repeating: if you have pityrosporum folliculitis you must avoid most oils and fatty acids. I say “most oils” because there are 3 that we can use (more about this in the next section).
To have it handy, here’s a list of the main 11-24 fatty acids you need to steer clear of.
- Undecylenic Acid (C11)
- Lauric / Dodecanoic (C12)
- Tridecylic (C13)
- Myristic / Tetradecanoic (C14)
- Pentadecanoic (C15)
- Palmitic / Hexadecanoic (C16)
- Palmitoleic / Hexadecenoic (C16:1)
- Margaric (C17)
- Stearic / Octadecanoic (C18)
- Oleic / Octadecenoic (C18:1)
- Linoleic (C18:2)
- α-Linolenic (C18:3)
- Nonadecylic (C19)
- Arachidic / Eicosanoic (C20)
- Heneicosylic (C21)
- Behenic / Docosanoic (C22)
- Tricosylic (C23)
- Lignoceric / Tetracosanoic (C24)
Source: M. Nazzaro Porro, S. Passi, F. Caprilli, P. Nazzaro, G. Morpurgo. 1975. “Growth Requirements And Lipid Metabolism Of Pityrosporum Orbiculare.” Institute of Dermatology, St. Gallicano, Rome, Italy.
And for reference, here a list of fatty acids 4 through 38. Remember: it’s just the 11-24 that you need to avoid.
The ones that appear most in skincare products are even numbered. Particularly lauric, myristic, palmitic, stearic, oleic, and linoleic acid. You can find these by looking at the ingredient list on the back of your skincare products.
Be especially cautious of palmitic and oleic acid. These are actually used to induce the mycelial phase in vitro because they cause M. furfur to grow the fastest. (50)
Feel free to skip ahead, but for those interested, I’m gonna go into more detail about fatty acids here because not all fatty acids are treated equal.
Saying malassezia feeds on 11-24 carbon chain length fatty acids is catch all phrase used for safe measures. It’s technically a lot more complicated than that. One of the more recent studies in 2012 revealed that malassezia has different metabolic needs depending on what species within the group we’re referring to.
Pair that with the fact that malassezia varies tremendously depending on geographical location and…. well, it’s no wonder people say YMMV (your mileage may vary).
Moreover, the quantity of fatty acid is also important. Sometimes a fatty acid in small amounts causes malassezia to grow, whereas the same fatty acid in higher concentrations is actually toxic. Just take a look at this bar graph.
As you can see, the growth of this fungus is all over the damn place! It varies depending on the species, what fatty acids were used, and the concentration of those fatty acids. For example, when M. globosa is given 0.01% linoleic acid it grows, but in the presence of 0.1% linoleic acid it starts to die!
And lastly, some species grow slower than others. (51) The slow growth species are M. globosa, M. restricta and M. dermatis (these take about a week in vitro), and the fast growth species are M. sympodialis and M. furfur (grow within two days).
That’s why it’s important that you patch test your skincare products for at least a couple weeks! The last thing you wanna do is use a cream for 3 days and think, “Welp, I don’t see any problems, let me slater this puppy all over my face,” then a month later be like…. “WHAT THE HELL HAPPENED?!?!?”
Ah, esters…. I’ve been asked a lot about whether these will feed malassezia. It’s a bit complicated, but the answer is yes. However, it depends on what esters, alcohol moiety, and species of malassezia we’re talking about.
Seriously, as if this sh*t wasn’t complicated enough already…..
Let me try my best to simplify and explain this.
For those that don’t know, esters in skincare are a combination of a fatty acid with an alcohol or glycerol. This is called a fatty acid ester. For example, you can combine palmitic fatty acid with isopropyl alcohol (i.e. rubbing alcohol) and you get isopropyl palmitate — a common ingredient in many moisturizers like the popular Aveeno Daily Moisturizing Lotion.
You can use different types of alcohols for this process. For example, combining ethanol and linoleic acid gives you ethyl linoleate, whereas combining decyl alcohol and oleic acid gives you decyl oleate.
When a fatty acid is paired with glycerin (a.k.a. glycerol) instead of an alcohol you get a glyceride. For example, glycerin plus stearic acid gives you glyceryl stearate.
You can find esters in your skincare products easily because they end in -ATE, like isopropyl palmitate, decyl oleate, glyceryl stearate etc.
Hopefully, I haven’t lost you. Here’s all that info again.
- alcohol + fatty acid = ester
- glycerin + fatty acid = glyceride, also known as a glycerol ester.
- Esters in your skincare products end in -ATE.
Make sense? Cool. Now to put it into context.
Turns out that malassezia species can grow with esters, but it depends on what fatty acids and alcohols are present in those esters.
For example, 96 hour culture testing revealed that M. sympodialis grew in the presence of ethyl esters (specifically ethyl linoleate and ethyl oleate), whereas M. furfur (a species that causes pityrosporum folliculitis) only grew with ethyl linoleate. (52)
Moreover, some alcohols are worse than others. To quote a paper:
“Depending on the inoculum, yeast-dependent hydrolysis [by M. furfur] occurred immediately and was best effected in ethyl esters, followed by isopropyl esters, whereas hydrolysis of decyl oleate was only limited.” (53)
English = esters made with ethanol are the most problematic, followed by isopropyl alcohol esters, and decyl alcohol esters.
BUT, and this is a BIG BUTT.
The growth of malassezia with esters mostly depends on what fatty acid it yields after hydrolysis.
WOW. This is starting to sound way too complicated. I know what you’re probably thinking, “what the hell f.c., I thought this was SIMPLE skincare science?” You’re right. Let me back up for a second and reexplain.
Remember how we said malassezia feeds on fatty acids with carbon chain lengths 11-24? Well, when malassezia is exposed to an ester it breaks down the corresponding glycerol or alcohol component of that ester to utilize the fatty acid.
You know what? This would probably be easier explained over video, so uh…. here’s a video I made.
Hi there. Alright, we’re back.
Here’s the take away from the video: esters are bad if they contain fatty acids that are within the C11-C24 range. And what do you know, this has actually been demonstrated in a recent study. Check out this graph to see what I mean.
What you’re staring at is the hydrolysis of ethyl octanoate (i.e. an ester of ethanol and octanoate acid). In the photo above it begins as an ester, but turns into free octanoate acid after being exposed to M. sympodialis.
However, recall how octanoate acid has a carbon chain length of 8 meaning malassezia cannot metabolize it. Had it been another fatty acid within the 11-24 range, M. sympodialis would have used it as a food source to grow.
Here’s a quote from the research paper:
“Ethyl esters of medium chain fatty acids esp. ethyl octanoate [carbon chain length 8] can reverse the growth promoting effects [of malassezia] by generating a selective activation of antimicrobial activity esp. in areas well populated with Malassezia yeast (‘targeting’)…. Based on these data, fatty acid monoesters may represent a new therapeutic concept in M.-associated diseases.” (54)
English = malassezia works to separate the fatty acid from ethanol so it can use it as a food source. Only problem is that once it does this, octanoate acid is like, “BAM B*TCH! POISON. I got that CARBON 8 chain length!” Then malassezia starves to death. 🙂
Other esters that in vitro studies have shown malassezia can metabolize:
- PEG-7 Glyceryl Cocoate (a polyethylene glycol ester made from glycerin and coconut fatty acids)
- PEG-Glyceryl Stearate (PEG ester that breaks down into stearic acid)
- Polyethylene Glycol Stearates (mixture of mono and distearates with corresponding free glycols)
Note: polyethylene glycol monostearate was not metabolized by M. obtusa, M. globosa, M. restrica but was by M. furfur, M. sympodialis, M. slooffiae.
Interestingly enough, only M. furfur was able to metabolize PEG-35 castor oil. (55) And while we’re on the subject of hydrogenated oils, let me quickly insert a quote on that subject matter:
“After hydrogenation the fatty acid fraction proved to be at least as active in promoting growth as the original scalp-surface lipid. This indicated that the requirement for fatty acids was not confined to those with preformed double bonds.” (56)
In other words, hydrogenated oils are bad too. Avoid them.
So what the hell does all this mean for us? That it’s probably best to just avoid all esters, unless they’re made from capric or caprylic acid. However, I’ve yet to come across such esters in a skincare product.
For whatever it’s worth, I can use esters in my skincare routine ONLY WHEN I combine them with active ingredients or chemical exfoliants. Otherwise, they give me problems. If you want to play it extra safe and avoid anything potentially food grade for malassezia, then remove them from your routine.
If you’re wondering whether the small amount of esters in your skincare products can really cause problems — yes, yes they can. Just remember that studies have shown malassezia can metabolize fatty acids in quantities as small as 0.01%! I’m telling you, this thing a nightmare. (57)
Your “tweens” are polysorbates. These are esters. Specifically, ethoxylated sorbitan esters. The number you see at the end of them, for example polysorbate 20, corresponds to what fatty acid was used as the base during esterification.
- Polysorbate 20 = sorbitan monolaurate (lauric acid, C12)
- Polysorbate 40 =sorbitan monopalmitate (palmitic acid, C14)
- Polysorbate 60 =sorbitan monostearate (stearic acid, C18)
- Polysorbate 80 =sorbitan monooleate (oleic acid, C18:1)
The four polysorbates listed above all fed malassezia in vitro.
If you’re confused by all we’ve discussed so far — don’t worry! I’ve spend A LOT of time scourging far and wide for skincare products that have no esters, polysorbates, oils, and fatty acids. These are listed in the “best products” section below.
THESE DO NOT FEED MALASSEZIA! Can I get a woohoo? 😀 Here’s a quote directly from a research paper.
Fatty alcohols (Lanette E/N) and fatty acids in ether bond (Brij 721, Cremophor A 25) were not assimilated by any of the test strains. Therefore, these emulsifiers are suitable for topicals to be used in the treatment of seborrheic areas and when promoted growth of Malassezia yeasts is not desired. (61)
Exciting stuff, right? Here are the INCI names for the various emulsifiers/fatty alcohols listed above.
- Lanette E = Sodium Cetearyl Sulfate
- Lanette N = Cetearyl Alcohol (and) Sodium Cetearyl Sulfate
- Brij 721 = Steareth-21 (i.e. polyethylene glycol polymer and stearyl alcohol)
- Cremophor A 25 = Ceteareth-25
Note: Cetearyl Alcohol is a combination of cetyl and stearyl alcohols, so these should be fine too.
This was pretty mind-blowing news to me because I have long thought fatty alcohols were bad news, not realizing that it was actually ESTERS that were giving me problems.
And for whatever it’s worth, I recently had a conversation with a biochemist about whether he thought fatty alcohols would feed malassezia. We were discussing cetyl alcohol specifically, which is made from the reduction of palmitic fatty acid. Here’s what he had to say:
“Palmitic acid is a carboxylic acid so there’s a double-bonded oxygen on the same carbon as the alcohol; the lack of that oxygen is the structural difference between the two molecules [i.e. cetyl alcohol vs. palmitic acid]. A carboxylic acid structure will be more polar and that changes its solubility and other related properties.
The solubility properties of cetyl alcohol and palmitic acid are fairly different, so while I am not by any means certain because skin chemistry is complicated — there are a lot of factors involved, like buffers and enzymes on top of the more simple, straight organic chemistry stuff we’re covering here — I’d hazard a guess that cetyl alcohol would not be a feasible substitute [for malassezia].”
NOW GO SLATHER DEM FATTY ALCOHOLS ON YOUR FACE!
Specifically, galactomyces. I went into a lot of detail about this in my CORSX Galactomyces review, but the quick and dirty version is that malassezia increases the activity of the aryl hydrocarbon receptor (AhR), which has been linked to various skin diseases. (62)
People with Malassezia-associated diseases have a 10 to 1000-fold higher AhR-activating capacity compared to healthy controls. The takeaway = excess AhR activity is bad.
Guess what increases AhR? Galactomyces.
“In the present study, we found that GFF [galactomyces filtrate ferment] is a potent activator of AhR, as it induced the nuclear translocation of AhR and subsequent CYP1A1 upregulation.” (63)
I have found no evidence that the same applies to saccharomyces, a different but similar genus of fungi. However, that does not mean it won’t cause problems. TREAD LIGHTLY (as Walter White would say), should you try and experiment.
And report back here if you do because I’m too scared to do it on myself! :p
It turns out that some (not all) culture testing has shown cholesterol can induce the growth of mycelia in certain subspecies of M. furfur by about 20%. (66)
However, I don’t think cholesterol (a skin-repairing ingredient) is worth avoiding because I didn’t find this study all that convincing. Let me explain.
Firstly, cholesterol was only ever able to induce mycelium when combined with other esters that would yield problematic fatty acids. For example, combining cholesterol and cholesteryl stearate would yield stearic acid (carbon chain length 18) after hydrolysis. In this study, malassezia did metabolize that combination, but DID NOT metabolize cholesterol by itself.
Moreover, a more recent and vigorous study found that cholesterol and a few of its derivatives couldn’t induce mycelium at all. (67)
I’ve use products with cholesterol in the past with no problems.
Squalene is another ordinary part of human sebum and has minor effects on mycelium induction. (68) Malassezia can also induce squalene peroxidation in vitro, meaning it could theoretically contribute to the development of “normal” bacterial acne. (69, 70)
SQUALANE however (i.e. what’s found in most skincare products), is totally fine. I will discuss this in more detail in the “Oils That Won’t Aggravate Malassezia” section.
Fun fact #3: the skin surface lipids of people with seborrheic dermatitis are deficient in squalene and fatty acids, but rich in cholesterol and triglycerides compared to healthy controls. (71)
An in vitro study showed that phytosphingosine has observable growth on M. furfur. (72)
The findings of this study were a bit odd because phytosphingosine was able to inhibit malassezia in high concentrations, but for some odd reason leads to observable growth in small quantities.
I’ll let you decide whether this otherwise excellent repairing skincare ingredient is worth avoiding.
Additional Notes (Other)
If you’re suffering from “fungal acne” I would suggest you stay away from benzoyl peroxide. This may be confirmation bias, but it seems that many of us started having these issues from overzealously applying BP for several years. Thanks Dan from Acne.org.
I’m being facetious. :p
It kinda makes sense to me though…. Benzoyl peroxide breaks down into benzoic acid and oxygen upon contact with the skin. This kills bacteria, which I think can cause other microorganisms to flourish. And guess what actually NEEDS oxygen to thrive? Yup, none other than our lovely friend Mr. Malassezia.
Here’s a quote from a research paper.
“Requirement of oxygen was a must for multiplication of the fungus…. No growth was seen on plates incubated anaerobically [i.e. with no oxygen].” (73)
This may be a reason people find they CANNOT get rid of pityrosporum folliculitis with benzoyl peroxide. I know this definitely was the case for me. At the time, I thought my face was simply becoming “immune” to it despite the fact that BP doesn’t cause bacterial resistance.
In hindsight, I realize the reason I was still getting “acne” on BP was because it wasn’t acne at all. It was acne-like bumps caused by fungus not bacteria!
Amino Acids, Vitamins.
Not sure how pertinent this info is, but for whatever it’s worth — when asparagine (an amino acid), glycine, (another amino acid) thiamine (vitamin B1), and pyridoxine (vitamin B6) are in the presence of lipids they enhance the growth of malassezia. (74, 165)
Kinda makes me wonder if other B-complex vitamins like niacinamide pose the same threat…. Hmmm.
UPDATE 5/29/2017: I’ve been doing more research on amino acids, and I found another study that says these are bad in presence of other lipids (fats, fatty acids, oils, esters etc.) Here are a couple relevant quotes from a research paper:
“An amino nitrogen and a lipid source were sufficient to induce growth of M. furfur…. of the 21 amino acids tested, only cysteine supported no significant growth…. with some variations among the species tested, a broad spectrum of other amino acids can therefore induce hyphae.” (166)
Ceramides are the main component of the stratum corneum and epidermis, which are the two outer most layers of skin. They play an important role in the health and barrier function of skin. There’s a link between specific ceramide deficiencies and skin disease.
For example, psoriasis has decreased levels of ceramide 1, 3, and 6, whereas eczema and acneic skin is deficient in ceramides 1 through 6.
However, it gets a little tricky because not all ceramides are treated equal. One study found that dandruff, which is worsened by malassezia colonization, has decreased levels of ceramide 1 but increased levels of ceramide 6i and 6ii. (75)
Something else that causes me to raise an eyebrow about ceramides is their structure. They are composed of sphingosine and a fatty acid. Recall from the information above how M. furfur shows slight growth in the presence of other sphingoid bases like phytosphingosine.
I also tried to find information about what fatty acids are attached to the sphingosine component of ceramides. One study examined pig skin and found they were mostly C24 and C26 fatty acids. (76) How relevant this is to human skin, I don’t know.
More alarmingly however, is this patent about ceramides in skincare that states they can be manufactured with C16-C32 fatty acids! Not to mention, we have enzymes on the skin called ceramidases that break down ceramides into its respective parts (free sphingosines and fatty acids), which can then be utilized by malassezia.
Just a lot of what ifs, which is why I decided to experiment on myself. Heh heh. I formulated two moisturizers both without fatty acids, oils, esters, or fatty alcohols. However, one of them has ceramides, the other does not. Here’s a photo of the former.
My plan is to stop using all anti-fungals for the time being and use the ceramide-free version to see if i develop any malassezia clogs. If things stay clear then I’ll switch to the ceramide version. Should problems arise then I know it’s the ceramides.
For anyone wondering, here are the ingredients of the moisturizers:
Water, Capric/Caprylic Triglycerides, Urea, Petroleum Jelly, Dimethicone, Polyacrylate Crosspolymer-6, Glycerin, Centella Asiatica Extract, Green Tea Extract, Sodium Lauroyl Lactylate, Carbomer, Xanthan Gum, Propylene Glycol, Diazolidinyl Urea, Iodopropynyl Butylcarbamate, Citric Acid.
Water, Capric/Caprylic Triglycerides, Urea, Petroleum Jelly, Ceramide 3, Ceramide 6, Ceramide 9, Phytosphingosine, Cholesterol, Polyacrylate Crosspolymer-6, Glycerin, Centella Asiatica Extract, Green Tea Extract, Sodium Lauroyl Lactylate, Carbomer, Xanthan Gum, Propylene Glycol, Diazolidinyl Urea, Iodopropynyl Butylcarbamate, Citric Acid.
And that sexy COSDNA profile. 😀
I shall let everyone know how the experiment goes in a couple to a few weeks.
UPDATE 6/1/17: I am coming to the end of this experiment, and I got GOOD news. Ceramides kick ass! I’ve yet to experience any breakouts after formulating back them into my urea moisturizer. This has made me so ecstatic I even started using CeraVe Cream again.
My sister has followed in my footsteps. So far both of us are loving this moisturizer! I have spruced up my original review of it, and included some sneaky skin photos. :p Go check it out!
I’ve seen a few people throw around the idea of using coconut oil because it is an “anti-fungal.” DO NOT DO THIS. The reason people say that is because coconut oil contains octanoic acid which is anti-fungal in nature.
However, this only makes up 7.1% of its fatty acid composition. Lauric acid, which has a carbon chain length of 12, makes up 47% of coconut oil! This is a prime fatty acid for malassezia.
I don’t have access to the full paper because it’s from China, but the abstract states, “glycerin can promote the growth of the Malassezia furfur. Therefore, glycerin cannot be used as the additive for the drug susceptibility testing of Malassezia.” (167)
Not sure what to think of this, and good luck finding a product without glycerin. -_-
UPDATE 5/2917: found another study that says glycerin does not produce growth except in very high concentrations. (166) I don’t think it’s something you need to worry about unless you’re skin is EXTREMELY sensitive/reactive.
I’m not sure how I feel about this one. I’ve seen a few fungal acne sufferers say it worked for them, but it’s fatty acid composition looks questionable. (77)
- Palmitic (C16) = 16-34%.
- Stearic (C18) = 6-24%.
- Oleic (C18:1) = 25-58%.
- Linoleic (C18:2) = 6-17%.
Not only that, one study found neem extract wasn’t very effective against malassezia.
“Neem extract had the least of stabilities and inhibitory action among the natural remedies experimented.” (78)
The other natural remedies tested were rice water extract, lemon juice extract, and my personal favorite…. cow’s urine. 🙂
Note: all of these natural remedies except for cow’s urine worked marginally at best, and I can’t in good conscious recommend that you go put cow pee on your face. There are more effective and better “natural” alternatives you can try. I will list these in the “natural treatment” section below.
Contrary to popular belief malassezia cannot grow in the presence of sugars or carbohydrates, with the exception of M. pachydermatis, which can synthesize mannitol and sorbitol. (79)
However, M. pachydermatis is only present in 2% of all humans, and has rarely been found in diseased human skin. All other malassezia species cannot ferment sugars. (80)
Warm Weather and Sweating.
Malassezia probably grows in warmer climate because you’re more likely to sweat when it’s hot outside, and sweat is made of stuff like salt and lactic acid, which in the presence of lipids can cause malassezia to proliferate. (83)
If this information is helping you rationalize being a couch potato for fear of sweating — don’t let it. From one couch potato to another, yuh gotta EXERCISE!
One study found that M. sympodialis allergens are released at significantly higher rates at pH 6. (85) The same study also found that those with eczema tend to have higher skin pH compared to healthy controls.
No growth in vitro was observed when the pH was outside of 4.5 -8.0. This means that a highly alkaline or acidic environment probably kills malassezia. However, I recommend you stick to lower pH things like chemical exfoliants because alkaline substances (e.g. baking soda) are bad for skin health.
Keep in mind that, “sensitization to malassezia is most likely a combination of a dysfunctional skin barrier, genetic background, and environmental factors,” (86) as a pair of researchers put it, so practicing proper skincare with pH appropriate products is still in your best interest.
So…. just stop using everything and you’ll cure yourself. That’s it. End of blog post. Have a nice day.
Just kidding! XD But seriously, it’s kinda ridiculous how many things could theoretically promote the growth of malassezia. I think this table summarizes most of it.
In other words, if you have pathogenic malassezia avoid anything that has fatty acids with problematic carbon chain lengths (11-24). This includes FATTY ACIDS themselves, OILS, ESTERS, and POLYSORBATES.
Fatty alcohols are okay to use. They will not feed the satan yeast.
Squalene might give you problems. As might cholesterol and phospholipids, but that’s debatable. The same applies to ceramides.
Not seen in the chart above, but equally important: avoid fermented products, specifically GALACTOMYCES. Given the current research available, I don’t know whether the same applies to saccharomyces. Lactic-acid producing bacteria like lactobacillus is fine.
That’s a lot to avoid, but fear not because there’s still awesome stuff you can use.
For example, hydrocarbons — load up on this sexy mothers! This includes petroleum based products like vaseline and crude oils (e.g. mineral oil). Silicones are also a godsend. Use them generously. I love me some dimethicone. It makes your skin feel all smooth and protected. 🙂
If all this has been confusing / I’ve lost you, and you have no idea what the hell any of this stuff means, see the “best products for malassezia” section below. I have made a ton of product recommendations that are okay to use including cleansers, moisturizers, sunscreens, serums, exfoliants, toners, emulsions etc.
Oils That Won’t Aggravate Malassezia.
There are only three oils that are compatible with malassezia! They are:
1. MCT Oil.
A.k.a. caprylic/capric triglycerides, either in combination with each other or used separately. This is essentially coconut oil without the lauric fatty acid component, which allows it to remain liquid at room temperature.
The reason MCT oil won’t cause any problems for malassezia is because it’s made up of caprylic (octanoic) and capric (decanoic) acid (C8 and C10 respectively), which are two fatty acids that are outside the problematic C11-24 range we mentioned earlier.
I get a lot of questions about whether I oil cleanse. Yes. Yes, I do. And I use pure caprylic acid oil (see on Amazon) because culture testing has shown it’s the fatty acid that inhibits the growth of malassezia the most. More about this in the “pityrosporum folliculitis natural treatment” section.
2. Mineral Oil.
A.k.a. baby oil without fragrance. Mineral oil is an inert substance that has no fatty acids, (87) meaning there’s nothing for the skin to hydrolyze, so it technically won’t “feed” malassezia.
It’s might give problems because it’s fairly occlusive. Recall from the information above that excessively occluding the skin is bad when you have malassezia sensitivities.
I really don’t think this is something to worry about unless you leave it on the skin and live in a very humid environment or sweat a lot, since this could trap the natural oils/sweat you excrete.
3. Squalane Oil.
This is something I just discovered and will try in the future!
Similar to crude oils (e.g. mineral oil), squalane is a hydrocarbon derived by the hydrogenation of squalene. (88) This eliminates the double bonds which make it less susceptible to oxidation (i.e. has a longer shelf life than pure squalene).
Why am I excited about this?
For one, squalane is non-irritating up to 100% concentration and is a natural part of human skin! (89) Secondly, the skin surface lipids of people with seborrheic dermatitis are deficient in squalene vs. healthy controls. (90) Recall how seborrheic dermatitis is often caused by malassezia.
Furthermore, it’s generally a good idea to treat skin conditions by replenishing what they lack. (91)
And last but not least, squalene protects against UV radiation-induced oxidative stress (i.e. sun damage), is an anti-carcinogen, may have antibacterial and anti-fungal properties, and is just a damn good moisturizer! (92, 93)
I know I mentioned earlier that squalene can cause malassezia to proliferate, but this might not be the case for the skincare derived version (squalane). If you try it, let me know about your experiences!
UPDATE 5/2917: two people have shared their experiences so far, one said it helped get rid of the bumps that didn’t budge with AHAs, BHAs, tretinoin cream, and azelaic acid gel. The other said they used a product with squalane and broke out. Still up in the air, keep sharing!
UPDATE 6/10/17: More evidence that squalane is totally fine — it has a carbon chain length of 30!
Alrighty, now let’s go over the rest of the stuff you can use if you have malassezia problems.
Best Products for Pityrosporum Folliculitis.
None of the products listed below contain fatty acids or oils. However, some of them do have fatty alcohols or esters. I have marked the products below using the following.
- One asterisk (*) = has fatty alcohols. REMEMBER: these DO NOT feed malassezia! However, since many people say they have fatty alcohol sensitives, I’ve denoted them for convenience.
- Two asterisks (**) = has esters or polysorbates. These DO feed malassezia.
- Three asterisks (***) = has both esters and fatty alcohols.
If a product has no asterisk, that means its free of everything — oils, fatty acids, esters, and fatty alcohols, or essentially ANYTHING that could theoretically cause malassezia to grow or clog pores. I recommend choosing things that DO NOT have any asterisks when first starting off. After you have cleared your skin you may begin experimenting.
This is by no means a complete list. There are probably more products out there that I don’t know of. If you think I missed any feel free to let me know, and I’ll check the ingredient list to verify.
UPDATE 5/24/17: I just wanted to quickly say thanks to everyone who has been contributing! This is starting to look like a pretty hefty list of recommendations if I do say so myself. Things are looking up for us, Malassezia warriors! Can I get a helll yeaaaaaah??? 😀
Let’s be real, these aren’t that important because the ingredients aren’t left on skin. Don’t sweat this step. Just use something gentle within appropriate pH range ~5.5. I use and love the Vanicream Gentle Facial Cleanser.
It’s cheap, gentle, cleanses well, doesn’t dry my skin, and uses a fatty alcohol surfactant.
UPDATE 5/11/17: Here are some other cleanser options, thanks to everyone who’s been contributing!
- Avene Cleansing Foam
- Bioderma Sensibio Micellar Water (fantastic and gentle makeup remover)
- Cetaphil Gentle Skin Cleanser (Note: contains SLS which can irritate sensitive skin. The irony. Can also be used as a body wash)
- **Neutrogena Ultra Gentle Daily Foaming Cleanser
- Simple Refreshing Facial Wash Gel
UPDATE 5/9/17: I’ve been asked about body washes, here’s what I’ve been able to find so far.
- **Free & Clear Liquid Cleanser
- Neutrogena Body Clear Wash (Note: contains 2% salicylic acid)
- Premium 10% Sulfur Soap Cleansing Bar (Note: has saponified oil but sulfur is a great antifungal)
- Summer’s Eve Cleansing Wash (Note: this may be a lady parts wash, but it has a great low pH, is SUPER cheap, would work equally well on the body because it’s just a cleanser, and all the ingredients check out! I have no shame, and will definitely be purchasing this lmao). UPDATE 5/24/17: it has arrived at my residence! :^)
Oils and Oil Cleansers
- 100% Caprylic Acid Oil (what I’m currently testing, works just as well as MCT oil)
- MCT Oil (combination of capric and caprylic acid. Note: this is NOT the same as fractionated coconut oil! I used MCT oil for over a year and it works great)
- Mineral Oil (this is the most commonly used oil for OCM on r/skincareaddiction. It’s well tolerated and good for all skin types)
- Squalane Oil (I personally haven’t used this one, but it might work. Please share your experiences if you try it!)
Fun fact #4: to make your own oil cleanser simply mix 85-90% of your chosen oil with 10-15% cromollient SCE. Shake it and viola!
- **Acne.org 10% AHA
- COSRX AHA 7 Whitehead Power Liquid
- COSRX BHA Blackhead Power Liquid (Note: contains arginine. See section above about amino acids)
- Paula’s Choice 8% AHA Gel. (Full Review Here)
- **Paula’s Choice Regular Strength 2% BHA (Note: contains polysorbates)
- **Paula’s Choice Skin Perfecting 2% BHA (Note: contains polysorbates). (Full Review Here)
- Silk Naturals 2% BHA Toner
- Stratia Soft Touch AHA (10% Mandelic Acid)
- Stridex Pads (BHA). (Full Review Here)
Toners, Emulsions, Essences.
- Benton Snail Bee High Content Essence. (Full Review Here)
- COSRX Advanced Snail 96 Mucin Power Essence
- COSRX Propolis Light Ampule
- Hada Labo Hyaluronic Acid Lotion. (Full Review Here)
- Hada Labo Gokujyun Premium Lotion
- La Roche Posay Toleraine Fluid Emulsion (Note: the European version has shea butter)
- SkinFood Royal Honey Propolis Essence
- Bioderma Hydrabio Serum
- Mad Hippie Vitamin C Serum. (Full Review Here)
- Nufountain C20+Ferulic
- ****Paula’s Choice RESIST Super Antioxidant Concentrate Serum (Note: contains tiny tiny amounts of palm oil, second to last ingredient. Everything else is fine.)
- **Paula’s Choice RESIST Ultralight Super Antioxidant Concentrate Serum
- Skinceuticals C E Ferulic
- Stratia Rewind
- Topix Pharm Replenix CF Serum
It was really hard to find moisturizers that meet all this criteria. Benton Soothing Gel, Dr.Jart+ Water Drop Hydrating Moisturizer, and Sebamed Gel are probably you’re best bets. However, these may lack the richness of typical moisturizers because they’re free of thickeners like fatty alcohols.
- **Avene Skin Recovery Cream.
- Avène Tolérance Extrême Emulsion (Note: contains squalane)
- Benton Aloe Propolis Soothing Gel (Note: has propolis which inhibits malassezia)
- **Bioderma Hydrabio Legere
- *CeraVe Cream (Note: has ceramides). (Full review here)
- ***CeraVe Lotion (Note: has an isostearic acid ester, which is a combination of oleic and stearic acid).
- ***CeraVe PM (Note: also has an isostearic acid ester).
- **Clean and Clear Morning Burst Hydrating Gel Moisturizer
- Dr.Jart+ Water Drop Hydrating Moisturizer
- **Dr Lin Hydrating Gel. (Full review here)
- **EltaMD AM Therapy. (Full review here)
- **EltaMD Barrier Renewal Complex
- ***Eucerin 5% Urea Facial Cream (Note: urea inhibits the growth of malassezia. More about this in the “natural treatment options” section)
- Hada Labo Goku-jyun Perfect Gel (Note: contains urea and squalane. Someone try squalane oil already and tell us if it works damn it, cause this gel is looking hella’ SEXY, and is the only urea moisturizer without esters!)
- **Laneige Water Sleeping Mask. (Full review here)
- ****Scinic Honey All in One Ampoule (Note: contains tiny amounts PEG-60 Hydrogenated Castor Oil, but has a ton of amazing ingredients like niacinamide, centella asiatica extract, and malassezia inhibiting propolis/honey extract. I might try this in the future if I have the courage… unless someone beats me to it and tells me how it goes :p)
- Sebamed Clear Face Gel (Full review here)
- SunBurnt Advanced Recovery Gel
- ***Sebamed Urea Cream (Note: contains urea). (Full review here)
- ***U-Lactin Dry Skin Lotion (Note: contains urea)
Most sunscreens will contain esters that act as UV filters for photoprotection (e.g ethylhexyl methoxycinnamate). These esters are outside the problematic C11-C24 range, meaning they are completely fine to use and will not exacerbate malassezia.
- Biore UV Perfect Bright Milk SPF50 + PA ++++ (pink bottle = for face. Tinted slightly pink, which creates light-reflecting properties that make skin appear brighter. As far as I’m concerned, this shit is the fountain of youth. Check out what this 65 year old woman looks like. This is her sunscreen of choice)
- Biore UV Perfect Face Milk SPF 50 + PA ++++ (white bottle = for face. Similar formula as the above without the pink tint stuff.)
- Biore UV Perfect Milk SPF 50+ PA++++ (blue bottle = for face and body. Many people consider this the more economical version of the two above because it comes in a bigger tube and has a similar formula)
NOTE: all three of the Biore sunscreens above are water and sweat resistant. The blue and pink bottle versions were also the second place finishers in this AWESOME sunscreen experiment! The first place sunscreen has stearic fatty acid which we can’t use. -___-
- *CeraVe AM (Note: has ceramides)
- EltaMD UV Clear SPF 46 (Note: the tinted version contains esters, the original one does not.) (Full review here)
- Hada Labo Perfect UV Gel SPF50+ PA++++ (Note: this is the exact same thing as the Hada Labo UV Creamy Gel).
- **La Roche Posay Anthelios 50 Mineral Ultra Light Sunscreen Fluid
- La Roche Posay Anthelios AOX SPF 50 (Note: contains diethylhexyl syringylidenemalonate, which an ester that acts as an antioxidant and is outside the C11-C24 range)
- Shiseido Senka Aging Care UV Sunscreen SPF50+ PA++++
- Skin Aqua UV Moisture Milk SPF50+ PA+++ (Note: doesn’t contain alcohol)
- *Aquaphor Healing Ointment (Note: contains lanolin alcohol, which is funky ingredient. It’s technically a fatty alcohol, but pure lanolin has sterol esters)
- CeraVe Healing Ointment (Note: has ceramides).
UPDATE 5/16/17: I’ve been asked about this several times now, but it’s near impossible finding a liquid foundation that fits all this criteria. Your best off sticking to mineral powder as this usually only contains oxides and mica powder.
UPDATE 2 (5/29/17): You are all troopers! Here are some more options including liquid foundations. Thank Brittany and Mia for the solid contributions.
- Bare Minerals Original Foundation (powder)
- Bourjois Healthy Mix Foundation
- Glossier Perfecting Skin Tint (Note: this is a liquid foundation, but if you’re looking for decent coverage you won’t get it with this. I’ve watched a couple youtube videos of people demoing this, and it’s hardly noticeable on skin).
- L’Oreal Paris Infallible Pro-Matte Foundation
- Maybelline Superstay Better Skin Foundation
- NYX Total Control Liquid Drop Foundation
- NYX Pore Filler (this is a safe primer!)
- The Ordinary High-Spreadability Fluid Primer (a safe fluid primer)
Pityrosporum Folliculitis Treatment.
Now that we’ve gone over what to avoid with malassezia, let’s discuss how to TREAT it. Using products that are compatible with fungal acne will stop it from getting worse / slowly heal active lesions, but this process can be sped up if you come in with professional hitmen. These are your ANTI-FUNGALS.
Tom Busby over at the rosacea forums said it best,
“It’s easiest to understand the problem as a skin allergy and a fungal overload. Use an anti-fungal product to control the fungal overload and use an oil [or skincare products] that cannot be metabolized by malassezia [to keep it from flaring].”
Much like when treating acne, you got A LOT of options to choose from. We will be going over each so you can make the most informed decision possible. Let’s start.
Types of Anti-Fungals.
There are 6 types of anti-fungals. (94) They are:
- Allylamines (terbinafine) = this has anti-fungal activity against dermatophytes, molds, dimorphic fungi, and many types of yeasts. It stops fungus from accumulating squalene by disrupting fungal sterol biosynthesis. When taken orally, it’s delivered into the stratum corneum, nails, and hair through sebum.
- Azoles (bifonazole, itraconazole, and ketoconazole) = the largest group of anti-fungals. They work by disrupting the cell membrane of fungus (i.e. dissolve the fungal cell wall), which compromises it’s ability to grow and function properly. They have anti-inflammatory properties, are well tolerated, and have high efficacy rates especially when taken orally.
- Benzylamines (butenafine) = when applied topically residual fungicidal concentrations remain on the skin for up to 72 hours. It has anti-inflammatory properties, and reduces UVB-induced erythema, or the redness/red marks caused by the sun.
- Hydroxypyridones (ciclopirox) = synthetic anti-fungals that also possesses antibacterial and antinflammatory properties.
- Immunomodulators (pimecrolimus, tacrolimus) = work by weakening the activity of the immune system.
- Other = for example zinc pyrithione, which has keratolytic properties and helps shed fungus from the skin.
Study after study reveals that ketoconazole inhibits every species of malassezia. (95, 96, 97, 98, 99, 100, 101) This is why it’s the first stop for many people. Compared to other antifungals ketoconazole stacks up pretty well.
Let’s go over a few studies.
- 62 patients with pityrosporum folliculitis were given either ketoconazole (oral and topical; 200 mg and 2% shampoo daily), ketoconazole (oral only; 200 mg daily), econazole nitrate 1%, or miconazole nitrate 2% cream. There was 100% cure rate among the patients that used oral and topical ketoconazole. The ones who only used oral ketoconazole had 75% success rate. Topical econazolc and miconazole had a 90% failure rate. (103)
- 12 patients with pityrosporum folliculitis took 200 mg of oral ketoconazole once daily for 28 days. 10 out of 12 had a complete clearing, and the other two saw significant improvements. However, 2 months after stopping treatment all of them had relapsed. (104)
- 44 patients (35 men, 9 women) were asked to apply 2% ketoconazole cream twice daily or take 100 mg oral itraconazole. The 37 patients who used ketoconzole cream saw improvement on average after 27 to 43 days. The 7 patients who used oral itraconazole saw improvement after 14 to 18 days. There was no followup done. (105)
- 26 patients either used topical ketoconazole, oral ketoconazole, or both. Cure rates were 12%, 75% and 75% respectively. However, many relapsed after 3-4 months of stopping treatment. (106)
- A case report assessment in China found that malassezia folliculitis is diagnosed in 1.5% of all dermatological patients and treated most effectively with a sulfur-cleansing solution and topical ketoconazole. For more severe cases 200-400 mg of oral itraconazole is used for a week. (107)
- Treatment with 200 mg of oral itraconazole daily for 3 weeks resulted in clinical improvement in 93% of patients, whereas 84% responded to treatment with itraconazole 200 mg daily for one week. In other words, using azoles like ketoconazole for a bit longer leads to be better treatment outcomes. (108)
- 40 patients were either treated with 200 mg of ketoconazole and 2% ketoconazole shampoo daily, or 200 mg a day by itself. Everyone in the combination group had 100% clearing, whereas the systemic only group had 75% clearance (15 of 20 people). (109)
So on and so forth…. If you’re anything like me, reading these studies might be a little frustrating because there are a decent number of relapses The only time complete cure rates occurred was when oral anti-fungals were used in conjunction with topical ketoconazole.
This is because maintenance regimens are typically needed to keep malassezia in check unless you completely wipe out the little boogers from your system. A maintenance regimen usually means using topical ketoconazole once a week after you have completely cleared your skin.
However, this isn’t always necessary. In fact, a leading team of microbiologists and dermatologists concluded that malassezia folliculitis can be controlled with keratolytic agents after initial clearing with antifungals. (110)
This is what I recommend doing. That is, use an anti-fungal until your lesions are completely gone then follow it up with a keratolytic agent till the end of time. 🙂 That you way you won’t have to worry about anti-fungal resistance.
In my opinion, the most effective keratolytics for malassezia are sulfur and urea. I find both of these way more effective than salicylic acid. More about this in the “natural treatment” section. Retinoids like tretinoin or adapalene (differin) are other options to consider.
Side note: if you want to take an oral antifungal be aware that there was a recent FDA report of death risk with off-label oral ketoconzaole. (111) For this reason, I recommend talking to your healthcare provider about using itraconazole or fluconazole instead. These are generally safer and have fewer rates of relapse. (112, 113)
How to Use Ketoconzaole.
You may have noticed that a few of the studies above had patients use 2% ketoconazole shampoo to cleanse the affected areas of skin. This is currently the standard treatment protocol.
The usual recommended frequency with ketoconazole 2% shampoo is twice weekly over the span of 4 weeks. After the lesions have cleared, intermittent use of ketoconazole 2% shampoo (once weekly) has been shown to be effective in preventing relapse.
Also, make sure to leave the solution on your skin for about 3-5 minutes. Studies have shown that 5 minute contact therapy is more effective than simply applying and rinsing soon thereafter. (114)
Products with Ketoconazole.
- Nizoral A-D Anti-Dandruff Shampoo (1% Ketoconazole)
- Pet MD Chlorhexidine Wipes (1% Ketoconazole). Note: these may be doggy pads but they’re alcohol-free and would work just as well on human skin! Consider this the new stridex…. “STRIDEX IN A DOG BOX!“
Note: there are other azoles like clotrimazole and bifonazole you can try, but these have lower antifungal activity against malassezia, which is why I recommend trying ketoconazole first.
Climbazole and ketoconazole have almost identical in vitro activity against M. furfur. (115) Off of this study alone it’s hard to say which is better. For all and intents and purposes, it seems they’ll get the same job done on M. furfur. As far as I’m aware the other malassezia isolates have yet to be tested.
There was a more recent study in 2015 that showed 2% climbazole shampoo was very effective at reducing malassezia population sizes on the skin of infected doggies. Here’s a quote from that paper:
“2% climbazole shampoo application showed a significant and rapid reduction of Malassezia population sizes. One hour after the first climbazole shampoo application, Malassezia reduction was already statistically significant and 15 days after the second climbazole shampoo, Malassezia population sizes were still significantly decreased.” (116)
Products with Climbazole.
- Hegor Shampoo (1.5% Climbazole)
- Douxo Chlorhexidine PS Shampoo (0.5% Climbazole). Another doggy product. ¯\_(ツ)_/¯
- Sogeval Douxo 30 Count Pads (0.5% Climbazole). A.k.a. doggy stridex pads number 2!
Tom Busby from the Rosacea Forums has made a very comprehensive guide about how to compound your own climbazole lotion at home, which can be found here.
Interestingly enough, zinc pyrithione increases the levels of triglycerides, cholesterol, and ceramides (P<0.05) in the shampoo-treated scalp of dandruff patients. (121) In other words, it improves the skin’s natural barrier function.
I swear I once found a study that said zinc pyrithione works synergistically with ketoconazole, but I cannot locate the source anymore, :/ so take that with a grain of salt.
Products with Zinc Pyrithione.
Ciclopirox Olamine is a broad-spectrum antifungal with antibacterial and anti-inflammatory properties. (122) Testing has demonstrated it inhibits all the following species of fungi:
- Microsporum and Epidermophyton
- Cryptococcus Neoformans
- Sacchromyces Cerevisiae
- Aspergillus and Penicillium
And of course…
Malassezia, including all it’s main isolates (M. furfur, M. pachydermatis, M. sympodialis, M. globosa, M. obtusa, M. restricta, and M. slooffiae. It has an MIC range of 0.003-4 microg/mL. (123) For reference, ketoconazole has an MIC of 0.03-0.125 microg/mL.
In other words, it takes less ciclopirox olamine to inhibit malassezia compared to ketoconzaole. It also distinguishes itself other topical antifungals because it has broader spectrum and uniform activity against many microorganisms. (124, 125) It’s basically like an atomic bomb for all things microbes.
As for the studies….
- A 4-week, twice daily application has been used in the treatment of tinea pedis, tinea corporis, and scalp seborrheic dermatitis. (126)
- A case study of a 55 year old immunosuppressed liver transplant patient who completely eradicated M. furfur with ciclopirox olamine after 8 months. Note: he had M. furfur in his toe nails, which is far more difficult to eliminate than the skin on face/body. (127)
- An in vitro study that showed ciclopirox olamine used alone and in combination with zinc pyrithione was more effective than ketoconazole against M. globosa and M. restricta. (128) Moreover, 1.5% ciclopirox olamine inhibited both these strains by 99% after only 30 minutes!
- A case study of a woman who cleared her fungal acne by slathering a thick layer of ciclodan cream (0.77% ciclopirox olamine) every night. She said her skin cleared in about 3 weeks, and has incredible before and afters up on her blog. It’s been several years since she wrote this article and has yet to relapse. Link here.
Something else that is especially appealing about ciclopirox olamine, is that it doesn’t appear to create fungal or bacterial resistance. One study found that a 6 month incubation period of candida produced no resistance, which wasn’t the case for fluconazole. (129)
As a pair of researchers put it:
“A significant feature of CPO is that no single case of fungal resistance has been reported so far, even though it was introduced into clinical therapy more than three decades ago…. The steep dose–response curve noted for ciclopirox may aid in producing a fungicidal effect rather than a fungistatic effect, and may therefore limit development of resistance. Lack of resistance may also result from irreversible binding of ciclopirox to intracellular structures – noted by Sakurai – that prevents ciclopirox from being used as a substrate for the drug resistance pumps. The lack of effect of drug resistance pumps may allow ciclopirox to be used long-term without significant reductions in antifungal/ antibacterial efficacy. ” (130, 131)
It’s also very well tolerated.
Products with Ciclopirox Olamine.
Unfortunately, this a prescription only drug. Loprox (0.77% Ciclopirox Olamine), polish name Hascofungin, can sometimes be found on the bay of E…. but I never said this, nor am I responsible for whatever decisions you make with the information I am simply relaying here. Full disclaimer policy can be found here.
We only have one in vivo study on this antifungal but it looks very promising. Here’s how it went down….
10 Caucasian women with seborrheic dermatitis, oily skin, and post-adolescent acne were told to apply 1% butenafine HCl cream twice daily. By week one M. furfur was almost completely suppressed. By week two, M. furfur was essentially absent in every subject. And by week 3, six of the ten subjects had cleared their SD and the remaining four exhibited moderate improvement. (132)
There’s also this case study of a person who cleared their dandruff in a day when ketoconazole didn’t work. I’ve used butenafine hydrochloride in the past with much success.
Products with Butenafine Hydrochloride.
- Lotrimin Ultra cream (1% Butenafine Hydrochloride). Note: this is not the same as Lotrimin AF, which has 1% clotrimazole.
This is one of the only antifungals I have not tried, but it’s another option. An in vitro study showed it inhibited pityrosporum ovale and pityrosporum pachydermatis, but less effectively than ketoconazole. (133) There’s also concern about toxicity with prolonged use, or treatment on large areas. (134)
In terms of in vivo studies, I was only able to find one that involved 24 patients who were asked to apply selenium sulfide shampoo and leave it on for 30 minutes. They did this for 3 consecutive days, with subsequent treatment once a week. 22 of them were cured after 8 weeks. However, relapse occurred if treatment wasn’t continued intermittently. (135) The remaining two made improvements, but were ultimately cured with 200 mg of ketoconazole once daily for a month.
And lastly, there was a case study of a 21 year old female with malassezia folliculitis who cured herself after 10 days of applying 2.5% selenium sulfide cream for 10 minutes. She hadn’t relapsed during a 3 month followup. (136)
Products with Selenium Sulfide.
- Head and Shoulders Dandruff and Seborrheic Dermatitis Shampoo (1% Selenium Sulfide)
- Selsun Blue Medicated Dandruff Shampoo (1% Selenium Sulfide)
Pityrosporum Folliculitis Natural Treatment Options.
Because I know not everyone is comfortable with longterm use of anti-fungals, I will be going over all your “natural” treatment options. In my humble opinion, some of these (e.g. sulfur) work just as well if not better than antifungals.
Fun fact: azelaic acid is actually a byproduct of malassezia. (137) But don’t worry, this doesn’t mean it’s a bad thing. It’s often the byproducts of malassezia that are the things it can’t use.
There have been no vigorous research examining the effects of azelaic acid against malassezia. The only study I was able to find showed that 1% azelaic acid was able to suppress the growth of P. ovale in vitro. (138)
Recall how that’s one of the two subspecies of yeast that make up M. furfur. And mind you, azelaic acid creams generally come in 10-20%, so I’d expect it’s inhibitory powers to only go up with concentration.
Besides that weak evidence, I have my own theories as to why it would work. Let’s go over them!
Reason number one, it’s no secret I’m a big of azeliac acid. I’ve used it in the past with a lot of success against both acne and pityrosporum folliculitis. I know my anecdotal experience isn’t the most convincing scientific argument but uh…. azelaic acid is pretty cool ladies and gents.
Shout out to my reader Ian, who agrees! 😀 He’s used it for seborrheic dermatitis and acne. Here’s a quote directly from him:
“Discovering azelaic acid was a breakthrough for me…. In my experience, azelaic acid treats inflammatory acne better than non-inflammatory acne (whiteheads and blackheads). I was still getting a few stubborn whiteheads, so I added adapalene into my routine. My line of reasoning was that adapalene’s strengths are the inverse, in that it’s known to treat whiteheads and blackheads better than inflammatory acne.
Also, while Differin, like retinoids in general, is pretty lackluster as a monotherapy, it enhances the effectiveness of an ingredient used in combination with it. So basically I mix my own variation of Epiduo tailored for adult skin, replacing the BP with azelaic acid… The azelaic acid/adapalene combination works so well that I’m surprised that there isn’t a pre-mixed product available with it already.”
Reason number two, azeliac acid has been shown to work on both anaerobic and aerobic microorganisms. Recall from the info above that malassezia is aerobic, meaning it requires oxygen to grow.
P. acne on the other hand, (the bacteria that causes acne) is anaerobic, i.e. doesn’t require oxygen.
Aerobic, anaerobic — who f*cking cares! Azeliac acid kills em’ both. Heh heh. 😀
And reason number three, and what I find most convincing: azelaic acid reduces the overall fatty acid content of skin.
The composition of human sebum that has been exposed to pathogenic malassezia is abnormally high in free fatty acids.
Source: The Role of Sebaceous Gland Activity and Scalp Microfloral Metabolism in the Etiology of Seborrheic Dermatitis and Dandruff. (139)
One of the mechanisms by which antifungals work against malassezia folliculitis, is by regulating the free fatty acid content of skin. Azelaic acid has been shown to do exactly that. In fact, one study found that the level of free fatty acids was reduced from 15.9 to 10.5% after 1 month of using azelaic acid. (140)
Products with Azelaic Acid.
- Ecological Formulas Melazepam Cream (20% Azelaic Acid)
- GIGI Bioplasma Cream (15% Azelaic Acid)
- Skinoren / Finacea gel (20% Azelaic Acid). Note: this can sometimes be found on ebay.
Unfortunately, many products with Azelaic Acid contain problematic ingredients like esters and polysorbates. The high amount of azelaic acid might render these inconsequential. Ian described it best by saying, “in the best case scenario, it’s two steps forward, one step back.”
Caprylic Acid Oil
Like I mentioned above, MCT oil won’t cause malassezia flare-ups because it’s made from C8 and C10 fatty acids.
Recall how malassezia feeds on 11-24 carbon chain fatty acids. Caprylic and capric acid are both outside this problematic range.
- Caprylic / Octanoic acid = carbon chain length 8.
- Capric / Decanoic acid = carbon chain length 10.
And it turns out that caprylic acid specifically has the strongest antifungal properties. Here’s a quote from a research paper:
“We could confirm antimicrobial activity against the Malassezia and Candida spp. tested for the medium chain fatty acids capric acid C10, caprylic acid C8, and caproic acid C6. Caprylic/octanoic acid was most effective under the conditions given… Effectiveness can be graded as C 8 > C 6 > C 10. Especially with octanoic acid the Malassezia spp. M. globosa, M. sympodialis and M. pachydermatis seemed to be most sensitive… Less sensitive were the M. furfur, the C. parapsilosis and the C. krusei strains.” (141)
You can use pure caprylic acid oil to oil cleanse (what I do), or add a few drops of it into your moisturizer of choice. This is the one I use.
Cinnamic acid has antifungal activity against Malassezia species. (142) It’s obtained from cinnamon oil, balsams such as storax, or shea butter.
Just kidding… but not really. (143)
You can actually buy cow’s urine on Amazon. SAY WHAT?!
Green Tea Extract
Using 5% green tea extract in a bath 3 times weekly for 30 minutes kills M. sympodialis and heals eczema after 4 weeks. Here’s a photo from that study.
Products With Green Tea Extract.
Honey and Propolis Extract.
It’s no secret that honey has powerful antimicrobial effects against pathogens that cause skin disorders. Studies have shown that some variations of honey like manuka, scottish heather, and tualang inhibit the growth of staphylococcus aureus, pseudomonas aeruginosa, and escherichia coli. (144) This could be especially useful for those with eczema because S. aureus plays role in its pathology.
It’s effects on malassezia has been less studied, but I did find some research that showed honey is beneficial for seborrheic dermatitis and dandruff; recall how there is overlap with these and pityrosporum folliculitis. (145)
In one study, thirty patients with chronic seborrheic dermatitis were asked to apply a mixture of 90% raw honey and 10% water on affected areas for 3 hours every other day. After 4 weeks of this, all patients made improvements, with some completely healing their lesions. However, to prevent possible relapse it’s best to follow up with a weekly honey application for several months.
If you don’t like the idea of putting raw honey on your face, you can always try using products with honey extract or propolis.
And while we’re on the subject of propolis, interestingly enough two recent studies (in vitro and in vivo) showed that propolis extract exhibits antimicrobial activity against M. pachydermatis, staphylococcus, and candida (among other strains and species). (146, 147)
Note: the in vivo study was on doggies.
Bonus note: the composition of propolis varies depending on geographical location, what plant it came from, and the species of bees that made it. (148)
Products With Honey and/or Propolis.
- 100% Raw Manuka Honey
- Benton Aloe Propolis Soothing Gel (contains propolis)
- COSRX Propolis Light Ampule
- Scinic Honey All in One Ampoule (contains honey extract and propolis). Note: has PEG-60 hydrogenated castor oil, which feeds M. furfur.
- SkinFood Royal Honey Propolis Essence
This stuff is the bee’s kneeeeees!
I haven’t found any specific research on inhibitory powers of sulfur on malassezia, but I’m 100% sure it works, and work very well. Especially because many people have reported success with it online.
For example, this really awesome case study of someone who won their 14 year battle with tinea versicolor (caused by M. globosa) by taking sulfur baths a few times a week. And check out these incredible acne before and afters after using sulfur for just one month! Links here and here. I’m pretty sure the second link was pityrosporum folliculitis.
Anyway…. here’s what we do know:
Sulfur is a keratolytic (sloughs off dead skin), which promotes the shedding of fungus from the stratum corneum. (149) Secondly, when applied to skin, sulfur produces pentathionic acid which is toxic to fungi. (150) And it may also directly inhibit Malassezia.
So….. pretty much EVERYTHING. Notice the conditions I bolded. These are all pathologically similar, i.e. caused by Mr. Malassezia.
And then there’s the fact that sulfur has been used since Hippocrates’ day to cure all kinds of skin diseases. I once heard Plato had glowly skin. :p I’m telling you, those ancient greeks just knew something we didn’t.
In my opinion, sulfur is another one of those ingredients like urea that does not get nearly enough of the love it deserves. Also, have you ever heard anyone actually say something bad about it? For real, just read some online testimonies and you’ll be left astounded.
The only con of sulfur is that it smells like rotten eggs. Literally. But that’ll make for some interesting late nights and sleepovers with your significant other. 😉
Fun fact #5: my sister cured her hormonal adult acne with sulfur. I had my suspicions it was fungal related, but she never believed me.
Products with Sulfur.
- Durvet Nu-Stock Ointment (has 71% sulfur). This was the stuff the person used in their bath to eliminate tinea versicolor. Remember to DILUTE this!
- De La Cruz Sulfur Ointment (10% Sulfur). What I used in the past with MUCH success. This should only be left on skin for 10 minutes!
Like I always say on this blog — yes, sunscreen is important….. BUT SO IS VITAMIN D. Modest amounts of sun exposure is good for your health! What’s modest sun exposure? About 15 minutes a day when the UV index is 3 or greater.
Interestingly enough, sun exposure improves rosacea, eczema, acne, and seborrheic dermatitis. (154)
Products With Sunshine.
- The Outdoors
Tea tree oil.
Depending on the species of malassezia, it’s inhibitory concentration ranges from from 0.12%-1.0%. (161) Here’s a table with that data for everyone.
If you plan on using tea tree oil, make sure to dilute it at 1% concentration or less. Tea tree oil can be very irritating on the skin, so play it safe.
Also, try and source the “Melaleuca alternifolia,” variety of tea tree oil. This is the one used in studies.
Products with Tea Tree Oil.
This is a naturally occurring substance in urine, which is probably why some people swear by urine therapy. Yes, that’s actually a thing. But don’t try it! Just a damn urea cream instead.
Urea is a cool lad because it’s both a keratolytic and hydrating agent. Keratolytic meaning it exfoliates hardened dead skin. But unlike salicylic acid, which can dry the living daylights out of skin, urea is actually HYDRATING. That’s actually what it’s primary uses in dermatology are for (i.e. to deeply moisturize).
In addition to that we also have evidence that urea treats ichthyosis, xerosis, atopic
dermatitis/eczema, contact dermatitis, radiation induced dermatitis, psoriasis, seborrheic dermatitis, onychomycosis, tinea pedis, keratosis, and pruritus. (162)
Again, conditions in bold are caused by Malasseszia.
Fun fact #6: urea has been used to treat various skin diseases for over a century.
In my opinion, urea is the most underrated skincare ingredient available today. For the heck of it, here’s a sweet quote from Dr. Albert Kligman a.k.a. the dude and dermatologist who co-invented Retin-A!
“It sometimes happens in the enthusiastic search for new therapeutic agents that some old stand-by has been overlooked, whose luster has worn off, but which none the less may have some useful application in moments when the miracle drugs falter. In the world of topical therapy, urea is such a drug.” (163)
Wasn’t that beautiful? It’s all poetic and english major-like. And that was from 1957! Seriously, urea has flown under the radar for far too long. GO PUT SOME ON YUH FACES!
Products With Urea.
- Eucerin 5% Urea Facial Cream
- Hada Labo Goku-jyun Perfect Gel (contains unspecified amount of urea but it’s higher up in the ingredient list! Also has squalane oil, see section above about this)
- Sebamed Urea Cream
- U-Lactin Dry Skin Lotion
Note: all of these except Hada Labo Perfect Gel contain esters which feed malassezia. Again, this is like taking two steps forward and one step back. It’s why I’ve been formulating my own urea moisturizer. :p However, I’ve used Sebamed in the past with success when paired with stridex pads (salicylic acid).
Diet and Malassezia.
I can write a whole post about this too, but honestly I’m kinda exhausted from all the researching and writing this article took. Sorry. Just try to make healthier food choices and avoid prolonged use of broad spectrum antibiotics if they aren’t necessary. I’ll refer you to two of my guides that will help you get started on the nutrition side of things.
And we’ve made it! Phew. If you’re still with me, thanks for reading! I hope you’ve learned something new, and I wish you the best of luck on your skincare journey with malassezia. I’ll see you on the other side!
EDIT 5/29/2017: Please read the comments before asking a question. It’s probably been answered already! Thank you for being considerate.