Malassezia Folliculitis Presentation, Diagnosis, and Treatment: A Review of “Fungal Acne”
May 2026 | Volume 25 | Issue 5 | 427 | Copyright © May 2026
Published online April 30, 2026
Zoe D. Draelos MDa, John S. Barbieri MD MBAb, Emil A. Tanghetti MDc, Patricia Farris MDd, Edward (Ted) Lain MD MBAe, Samantha Prevete PharmDf, Su Yong Choi PharmDg, Karol Wroblewski PharmDf, Hilary Baldwin MDh,i, Leon H. Kircik MDj-l
aDermatology Consulting Services, PLLC, High Point, NC
bDepartment of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
cCenter for Dermatology and Laser Surgery, Sacramento, CA
dTulane University School of Medicine Department of Dermatology, New Orleans, LA
eAustin Institute for Clinical Research, Austin, TX
fRutgers University, New Brunswick, NJ
gOrtho Dermatologics*, Bridgewater, NJ
hThe Acne Treatment and Research Center, Brooklyn, NY
iRobert Wood Johnson University Hospital, New Brunswick, NJ
jIcahn School of Medicine at Mount Sinai, New York, NY
kIndiana University School of Medicine, Indianapolis, IN
lPhysicians Skin Care, PLLC, DermResearch, PLLC, and Skin Sciences, PLLC, Louisville, KY
Abstract
Background: Malassezia folliculitis (MF), commonly referred to as "fungal acne" is a dermatological condition caused by colonization of the commensal fungus Malassezia, which turns pathogenic under certain conditions. MF presents as pruritic, erythematous papules and pustules and is often mistaken for other dermatological conditions, including acne vulgaris (AV). Interest in MF has intensified in recent years, likely due to social media trends, leading to concern regarding patients inappropriately applying antifungals without a confirmed diagnosis.
Methods: This narrative review summarizes the prevalence of MF, risk factors for the condition, MF pathogenesis, diagnosis, and treatment options.
Results: MF prevalence varies by geographic region and is higher in patients diagnosed with AV versus the general population. Risk factors include hot, humid weather, hair follicle occlusion, and immunocompromise. Increased sebum production, lipase activity, and inflammation contribute to the pathogenesis of both MF and AV. MF diagnosis includes clinical presentation and confirmatory tests such as direct microscopy and histopathology. The mainstay of treatment is antifungal medication, though given shared pathogenic mechanisms between AV and MF, acne topicals that target pathogenesis of both conditions, including benzoyl peroxide and retinoids, may be beneficial.
Conclusion: Clinical presentation of MF resembles that of AV and other skin conditions, leading to misdiagnosis, delays in treatment, and persistence of MF in patients for years. This underscores the need for appropriate diagnosis and timely treatment. Given shared pathogenic mechanisms between AV and MF, further investigation of acne topicals that target the pathogenesis of both conditions for the treatment of MF is warranted.
INTRODUCTION
Malassezia folliculitis (MF) is a lipid-dependent fungus that thrives on the lipid composition of sebum in the sebaceous glands of hair follicles and the stratum corneum.1,2 Malassezia was previously referred to as Pityrosporum and was composed of only 3 species; however, at the end of the 1990s, the Malassezia genus was recognized, and the previous Pityrosporum fungi were incorporated into the genus.3-5 To date, 18 species of Malassezia have been identified, with M. restricta, globosa, furfur, sympodialis, and pachydermatis frequently isolated from human skin.6
Although Malassezia is a commensal fungus and is the most prevalent fungal genus present on healthy skin,2,3 it becomes pathogenic under certain conditions and is implicated in several skin disorders, including pityriasis versicolor, seborrheic
