Fungal acne vs hormonal acne
They share a word and very little else. Fungal acne is a yeast overgrowth in the hair follicles and is treated with antifungals. Hormonal acne is ordinary acne that flares with hormone changes, and is treated with acne medication and sometimes hormonal therapy. Treating one as the other usually does nothing, and antibiotics for acne are the trigger most often named for fungal acne.
Products matter differently for each. The fungal acne checker reads a label for what Malassezia yeast can feed on, and the comedogenic ingredient checker reads it for pore-clogging ingredients, which is the question for ordinary acne.
Side by side
| Fungal acne | Hormonal acne | |
|---|---|---|
| What it is | Malassezia yeast overgrowing in hair follicles | Acne vulgaris that flares with hormone changes |
| What the bumps look like | Many small papules and pustules, 1 to 2 mm, all alike; no blackheads or whiteheads | Acne lesions of mixed kinds, which can include blackheads, whiteheads, pimples, nodules and cysts |
| Itch | Common | Not described in the sources used here |
| Where | Forehead into the hairline, upper back, chest, upper arms | Often said to be the jawline and lower face, a view a 2017 review says has been challenged |
| Named triggers | Antibiotics, heat, sweat, oily skin, occlusion, a weakened immune system | Periods, pregnancy, perimenopause and menopause, starting or stopping the pill, stress |
| Treatment | Antifungals, on the skin or as tablets | Acne medication; in women, sometimes the pill or spironolactone |
Fungal acne, in more detail
Malassezia folliculitis is commonly misdiagnosed as ordinary acne and can persist for years on typical acne medication. Oral antifungals are the most effective treatment, and when it comes with ordinary acne both kinds of treatment may be needed (Rubenstein and Malerich, 2014). In a review of 110 young patients, more than 75 percent had recently taken antibiotics for acne, 65 percent reported itch where it was recorded, and the bumps were fine and uniform on the forehead, hairline and upper back (Prindaville and colleagues, 2018). DermNet notes comedones are not seen, which separates it from acne vulgaris (DermNet).
The rest is on what causes fungal acne and how to get rid of fungal acne.
Hormonal acne, in more detail
Hormonal acne is ordinary acne in which hormone changes are the main driver, most often discussed in adult women. The American Academy of Dermatology names fluctuating hormones around periods, in pregnancy, perimenopause and menopause, and after starting or stopping birth control pills, along with stress, family history and hair and skin products (AAD, adult acne).
For treatment, the AAD names two hormonal therapies that can clear acne in women: oral contraceptive pills, some of which the FDA has approved for acne, and spironolactone. It says women with acne along the jawline and lower face tend to do well on them (AAD, hormonal therapy).
The jawline rule is weaker than it sounds. A 2017 review of adult female acne notes that the long-held view that it appears on the lower third of the face has been challenged, and that good prospective studies of where it appears are lacking (Zeichner and colleagues, 2017). Where the spots are is a hint at best.
How to tell which you have
A doctor can look for the yeast in a scraping or swab, which settles the fungal question. Before that, three things are worth noting down to take with you: whether the bumps itch, whether they are all the same size with no blackheads or whiteheads, and whether they started or worsened after a course of antibiotics or around your cycle. This site shows no photographs of either condition. DermNet carries licensed clinical ones on its Malassezia folliculitis page.
Common questions
What is the difference between fungal acne and hormonal acne?
Fungal acne is Malassezia folliculitis, an overgrowth of yeast in the hair follicles, and it is treated with antifungals. Hormonal acne is ordinary acne, with blocked pores and bacteria, that flares with hormone changes such as periods, pregnancy, menopause or starting and stopping the pill. It is treated with acne medication, and in women sometimes with hormonal therapy.
Can you have fungal acne and hormonal acne at the same time?
Yes. A 2014 review notes that fungal acne is often associated with ordinary acne and that combining antifungal and acne medication may be needed. That overlap is one reason a test matters.
Does hormonal acne itch?
The sources used here do not describe itch as a feature of hormonal acne. Itch is common in fungal acne: in one series of 110 patients, 65 percent reported it where it was recorded. Itchy bumps are a reason to ask a doctor about fungal acne specifically.
Is jawline acne always hormonal?
No. The American Academy of Dermatology says women with acne along the jawline and lower face tend to respond well to hormonal therapy, but a 2017 review of adult female acne notes that the idea that it sits on the lower third of the face has been challenged and that good studies of where it appears are lacking.
Check a product for fungal acne
Paste an ingredient list and the checker marks anything in the four classes lab studies found Malassezia can feed on, with the study behind each rule.
More questions about breakouts
Sources used on this page
- Rubenstein RM, Malerich SA. “Malassezia (pityrosporum) folliculitis.” Journal of Clinical and Aesthetic Dermatology, March 2014;7(3):37–41. (opens in a new tab) A review of how the condition presents and how it is diagnosed and treated.
- Prindaville B, Belazarian L, Levin NA, Wiss K. “Pityrosporum folliculitis: a retrospective review of 110 cases.” Journal of the American Academy of Dermatology, March 2018;78(3):511–514. doi:10.1016/j.jaad.2017.11.022 (opens in a new tab) 110 patients aged 0 to 21 with the diagnosis confirmed by a potassium hydroxide preparation. More than 75 percent had acne recently treated with antibiotics, and 65 percent reported itch where it was recorded. The picture was numerous 1 to 2 mm uniform papules and pustules, typically on the forehead extending into the hairline and on the upper back. Ketoconazole shampoo was the most common treatment and improved or cleared most cases; some patients needed oral azole antifungals.
- DermNet, “Malassezia folliculitis”. (opens in a new tab) Risk factors listed: a hot humid climate, high sebum production, excessive sweating, occlusion from emollients and sunscreens, antibiotic use, and immunosuppression including steroid use. Sites: the upper back and chest, and also the forehead and hairline, chin, neck and upper arms. Comedones are not seen, which distinguishes it from acne vulgaris. Diagnosis is confirmed by finding the yeast in a scraping, tape strip, swab or biopsy. Topical selenium sulfide, econazole and ketoconazole work in most cases but may need a longer course than tablets; recurrence is common, and weekly topical use can serve as maintenance. The page carries clinical photographs.
- American Academy of Dermatology, “Adult acne”. (opens in a new tab) Names fluctuating hormone levels (around periods, in pregnancy, perimenopause and menopause, and after starting or stopping birth control pills), stress, family history, hair and skin care products, medicines and undiagnosed conditions as reasons for adult acne.
- American Academy of Dermatology, “Hormonal therapy: How it helps treat acne”. (opens in a new tab) Two hormonal therapies that can clear acne in women: oral contraceptive pills, some of which the FDA has approved for acne, and spironolactone. Women with acne along the jawline and lower face tend to have good results from it.
- Zeichner JA, Baldwin HE, Cook-Bolden FE, Eichenfield LF, Fallon-Friedlander S, Rodriguez DA. “Emerging issues in adult female acne.” Journal of Clinical and Aesthetic Dermatology, January 2017;10(1):37–46. (opens in a new tab) A review. The long-held view that acne in adult women develops on the lower third of the face has been challenged, and the authors note a lack of good prospective studies of its distribution.