Decoding acne: How hormones, fungi, follicles trigger breakouts

Dermatologist checking a woman's skin. [Courtesy/GettyImages] Acne is among the most widespread skin conditions globally, affecting individuals of all ages-though it's most commonly linked to adolescence. However, acne isn't a uniform condition; it appears in different forms, stems from various underlying causes, and is frequently misdiagnosed. Dr Hashim Shaukatali Kaderbhai, the section head and consultant dermatologist at Aga Khan University Hospital, explains that the term 'acne' is frequently used to describe different skin conditions, leading to confusion, especially when distinguishing between hormonal acne and fungal acne. Acne occurs when hair follicles become clogged with oil (sebum) and dead skin cells, resulting in pimples, blackheads, whiteheads or deeper cysts. According to the American Academy of Dermatology (AAD), acne is the most prevalent skin condition seen in dermatology clinics, with hormonal and fungal types being common yet often confused. "Hormonal acne, often mislabelled, refers to adult acne that flares due to hormonal shifts, especially in women during menstruation, pregnancy or in conditions like Polycystic Ovary Syndrome (PCOS)," explains Dr Kaderbhai. It typically appears on the lower face, including the jawline, chin and neck, and often manifests as painful pimples or cysts. "Hormonal acne is essentially adult acne, also called acne vulgaris," says Dr Kaderbhai. Although hormonal acne is often associated with women, due to menstrual cycles, pregnancy, and conditions like PCOS, men are also susceptible. Dr Kaderbhai notes that men naturally produce more sebum due to higher testosterone levels, making them equally prone to acne. "Testosterone, even in healthy levels, stimulates the sebaceous glands, which can clog pores and trigger breakouts," he explains. Unlike women, whose acne fluctuates with hormonal cycles, men typically experience more consistent acne, particularly on the face, back and shoulders. This means hormonal acne is not limited to female reproductive changes; it's also related to baseline hormonal makeup, making it a condition that can affect all genders. Fungal acne, medically known as Malassezia folliculitis, is caused by the Malassezia fungus, a yeast that infects the hair follicles. It appears as itchy, uniform pustules, often on the forehead, chest and back. "Fungal acne thrives in sweat, humidity and poor hygiene. Even scalp yeast can trickle down and cause flare-ups," Dr Kaderbhai notes. Another common form of acne seen in teenagers and makeup users is comedonal acne, which features blackheads and whiteheads, primarily on the T-zone (forehead, nose and chin). It's often caused by poor skin hygiene, makeup residue or oil build-up from exposure to pollution and sweat. While internal hormonal changes play a significant role in adult acne, especially during puberty, menstrual cycles, stress or pregnancy, fungal acne is mainly influenced by external factors like sweating, tight clothing, humid environments or re-wearing unwashed clothes. Comedonal acne is largely driven by surface issues such as cosmetic residue and pore build-up. Dr Kaderbhai emphasises that it's possible for someone to experience multiple types of acne simultaneously. "A person can have hormonal acne, fungal acne, and even comedonal acne all at once, especially if they have poor hygiene, use heavy makeup, or have an underlying hormonal imbalance." Hormonal acne often presents with deep, painful cystic or pustular breakouts concentrated around the lower face. "Hormonal acne can also appear on other parts of the body, like the back and chest," explains Dr Kaderbhai. Fungal acne is characterised by small, itchy, uniform pustules, typically more superficial, and usually appears on the upper body, particularly the forehead, chest and areas around the scalp. "Fungal acne is often mistaken for regular acne, but its key distinguishing factor is its distribution, which tends to be more focused on the upper body," Dr Kaderbhai notes. To prevent hormonal acne, Dr Kaderbhai advises maintaining a consistent skincare routine with gentle cleansing and oil-free moisturisers. Managing stress and avoiding frequent face-touching are also essential, as these habits can introduce bacteria and aggravate breakouts. For women experiencing hormonal fluctuations, addressing conditions like PCOS with diet, exercise, and medical treatment can be beneficial. Preventing fungal acne relies heavily on hygiene and keeping the skin dry, especially after sweating. "Avoid tight clothing, wash your hair regularly to prevent fungal transfer, and keep your skin dry," he advises. Those living in hot, humid environments are especially vulnerable, as the fungus thrives in such conditions. Dr Kaderbhai dispels the long-held belief that foods like eggs or meat cause acne, particularly in teenagers. "You cannot be allergic to a protein without a confirmed diagnosis. Eliminating nutritious foods based on assumptions can be harmful," he says. However, he acknowledges that certain foods can aggravate acne, such as high-glycaemic foods (biscuits, soda, chocolate), dairy products (milk, cheese, yogurt), and greasy, deep-fried foods (chips, mandazi). "These don't cause acne but can act as catalysts for someone already prone to breakouts," he explains. As more young people self-diagnose based on social media or hearsay, misdiagnosis has become common. Dr Kaderbhai advises patients to stop stressing over skincare ingredients and instead photograph the products they use and share them with a doctor for guidance. "You don't need to understand all the ingredients, just be aware and seek professional advice," he says. For treatment, hormonal acne may require topical retinoids, antibiotics or hormonal therapies like birth control pills or spironolactone. Fungal acne, however, demands antifungal creams or oral medications, as traditional acne treatments do not work for it. Comedonal acne is best managed with proper cleansing routines, non-comedogenic products and regular gentle exfoliation. "Understanding your acne type is half the treatment," Dr Kaderbhai says. "Without that, you're just throwing treatments blindly." He also highlights the importance of using acne imagery that reflects darker skin tones to prevent misrepresentation and improve education for both patients and professionals. Whether hormonal, fungal or comedonal, acne is more than just a cosmetic concern. It deserves the right diagnosis and treatment. With the correct knowledge and guidance, clearer skin is within reach.

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