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Concern · Acne · Malassezia folliculitis

P. 27 · GUIDE

The acne
that isn't acne.

Won't respond to BHA. Needs antifungals — diagnosis first.

Malassezia folliculitis — small, monomorphic, itchy papules on the forehead, chest, and back that look like acne and respond to none of the acne treatments. Fungal, not bacterial. Different category, different protocol.

— § 01

The triggers worth tracking.

Uniform 1–2mm papules, all the same size

The defining sign. True acne lesions vary in size; Malassezia lesions are monomorphic.

92%
Distribution: forehead, hairline, chest, back

The sebaceous-rich, sweat-rich zones. Particularly common in humid climates and after gym sessions.

85%
Itchy, not painful

True acne is usually painful or sore; fungal acne itches. Patients often describe scratching in their sleep.

78%
Worsens on antibiotic acne treatment

The diagnostic giveaway. If clindamycin makes things worse, you are not treating bacteria.

58%
⁂

— § 02

Ingredients that actually work.

Tier
Molecule
Role
Evidence
Tier A
Ketoconazole 2% shampoo (as wash)
Antifungal
First-line. Apply to wet skin, lather, leave 5 minutes, rinse. 3× per week.
Tier A
Selenium sulphide 2.5% wash
Antifungal
Equivalent to ketoconazole for body sites. Useful for chest and back.
Tier B
Zinc pyrithione 1% wash
Antifungal + bactericidal
Gentler; daily-use alternative once cleared. Maintenance role.
Tier A
Itraconazole oral (clinic)
Systemic antifungal
For widespread or stubborn cases. 1-week course usually clears.
Tier A
Squalane / oat-based moisturisers
Malassezia-friendly
Avoid esters, fatty alcohols, oleic-rich oils — Malassezia feeds on C11–C24 fatty acids.
⁂

— § 03

The protocol.

  1. Phase 01 · Week 1–4

    Antifungal washes

    Ketoconazole 2% wash on affected sites 3× per week, 5-minute dwell. Switch all moisturisers to Malassezia-friendly options.

  2. Phase 02 · Week 4–8

    Reassess

    If 60–80% improved, continue another 4 weeks then transition to weekly maintenance. If unchanged, see a clinician for itraconazole.

  3. Phase 03 · Month 3+

    Maintenance

    Weekly ketoconazole wash; humidity precautions; immediate post-gym shower. Recurrence is common; expect to maintain.

Bottom line

The single most important step is recognising the category. Treating Malassezia with adapalene + BPO for six months is a common, expensive, and frustrating dead end.