Let me preface this by saying that I’m not a doctor, and, more importantly, I am not your doctor. The approach I put in here is something I cobbled together by gathering skincare advice from multiple sources, and one that I think is kind of difficult to misuse to the point of doing real harm. That said, don’t use any of the recommended products if you’re allergic to them or they’re otherwise contraindicated for you. Be safe!

I don’t want to get into a long macrocosm vs microcosm preamble here, but it really is remarkable how much our own personal microbiologies resemble dirt.

I mean it. When land is cultivated, the soil appears to be mostly fine particles, like silt, sand, and clay. Its biology is bacteria-dominant, and there aren’t a lot of fungi around. If the land is left alone, annual weeds will give way to larger perennials, shrubs, trees, and eventually old growth forests. These drop layers of branches and leaves, fungal spores move in to break them down, and you get a rich layer of organic matter with its own diverse microbiome.
It’s fascinating stuff, if you’re a fan of dirt.
(I am.)

All of this is to say that the ground and the things growing in it are healthier when they can benefit from a variety of microorganisms, and so is your face. This is something I knew on a logical level, but seeing it play out is kind of another animal entirely.
Follow me here for a minute.

Just before Thanksgiving, I had a very minor surgery. It really wasn’t a problem — I was in and out in an hour, and all I needed was a local anesthetic. Afterward, I got a much-needed prescription for 300 mg clindamycin and was sent on my happy (if achy and puffy) way.

Though I am a huge proponent of herbal and traditional medicines, I also know that a lot of not-even-that ancient people died of things that are easily treatable today. Clindamycin is a lifesaver. If you’re like me, and members of the -cillin family are verboten to you, or you have an infection that’s resistant to other first line antibiotics, it may also be the only thing standing between you and a very bad outcome.

Despite its usefulness, clindamycin has always caused problems for me about a week or so after taking it. I feel a heat in my cheeks, which turns into a prolific, itchy, bumpy rash of tiny pimples. After this happened enough times for me, I attempted a tentative self-diagnosis: Malassezia folliculitis, also known as Pityrosporum folliculitis or fungal acne.

Malassezia is a genus of fungi that colonizes the skin of animals. It’s usually the opposite of a problem — under normal conditions, you don’t want your skin to be sterile. Like the microorganisms that live in your intestines, it’s part of a (hopefully) diverse biome where everyone serves their own tiny function.

Alas, problems arise when antibiotic therapy kills off the other microorganisms that compete with Malassezia. Since fungi aren’t affected by antibiotics, this leaves your skin completely at the fungus’ mercy. It’s the same reason why antibiotics often cause diarrhea. When they kill off your healthy gut biome, whatever pathogens that aren’t affected get to have a field day. The same thing that happens to your intestines can happen to your skin.

In the past, I used to just tank it. I’d deal with having a rash for a few weeks, and things would eventually get back to normal. I didn’t know why this happened, and nobody could really give me a good answer, but since it was self-limiting and I don’t often need antibiotics, I figured the itching rash was just a thing I had to deal with on rare occasions.

But not this time. If there was a way to keep from looking like the Toxic Avenger and feeling like I wanted to tear my own face off, I was all for it.

Turns out, there is a simple treatment for it: Fluconazole. Yay!

One of the potential side-effects of fluconazole is liver damage. Shit!

It can take care of a fungal skin rash pretty quickly. Yay!

It can also cause a skin rash. Shit!

Anyway. In the interest of not resigning myself to having to alternate an antibiotic and fluconazole every time I got an infection, I figured I’d try to take matters into my own hands. Luckily, I was successful.

So, how can you get rid of Malassezia/Pityrosporum folliculitis following treatment with oral clindamycin? With these:

• A bottle of Nizoral shampoo.
• A bottle of sulfur-based anti-dandruff shampoo.
• A bottle of The Ordinary’s Niacinamide 10% + Zinc 1% serum. Don’t get it from Amazon — there are reports of people getting counterfeit or expired product, and it’s pretty fast and cheap to get from Ulta, Sephora, or The Ordinary as it is.
• Fresh garlic.
• Water kefir.
• Turmeric and ginger tea.
• The ability to tolerate a boring diet for a while.

I also had a bottle of Hibiclens left over for Reasons, so I figured I’d give it a try. I cannot recommend this, since a) Hibiclens isn’t meant to clear up fungal acne or b) be used as a facial cleanser, and c) you will feel like you’re huffing several dozen ruptured cans of Lysol if you ignore those two things and use it anyway.

Nizoral contains ketoconazole, an antifungal. Anti-dandruff shampoos contain a variety of other antifungals. Both of these are used in the treatment of Tinea versicolor, which is caused by Malassezia globus. Niacinamide helps regulate sebum production and is effective at inhibiting Candida albicans, a skin-colonizing yeast similar to Malassezia. (It hasn’t been tested against Malassezia specifically from what I gather, but I figured it couldn’t hurt.) Similarly, turmeric has been shown to inhibit the growth of 22 fungi species, also including Candida.

You can use Selsun Blue or Head & Shoulders instead of the sulfur shampoo, if that’s what’s available to you. Selsun Blue and clinical strength Head & Shoulders contain selenium sulfide, which is an effective antifungal. Selenium sulfide has been found to be carcinogenic in rodents, but this was after it was administered orally. Since selenium sulfide isn’t absorbed through healthy skin, shampoos containing this ingredient are considered safe. However, if you have broken skin, you can end up absorbing some selenium sulfide because your skin’s barrier is compromised.

So, armed with an array of shampoos and assorted other things, I started a multi-pronged approach that focused on reducing the level of Malassezia topically and internally, and repopulating me with competitive beneficial bacteria. Kind of like removing noxious weeds before seeding a healthy, diverse garden.
Here’s what I did:

1. In the morning, I washed my face with either the Nizoral or the sulfur shampoo. I followed this immediately with the niacinamide serum.
2. In the evening, I’d wash my face again with whatever shampoo I hadn’t used in the morning. I’d let it stay on my face, like a mask, for about three minutes before rinsing. I’d follow this with more niacinamide.
3. I severely reduced the amount of sugar I was eating. Microorganisms can’t get enough of the stuff.
4. I ate raw garlic. This was probably not strictly necessary, but I felt like it couldn’t hurt.
5. I drank water kefir. This is a probiotic. If you make it yourself, and don’t back sweeten it, it can also be very low in sugar. (About 3g a serving.)
6. I drank two to three cups of turmeric and ginger tea a day.
7. I didn’t load my skin up with other products. Some moisturizers and serums contain ingredients that fungi can feed on, so I wanted to avoid them.
8. I slept on my back. This kept my skin away from my pillow. Even with changing the case every day, I felt like this offered some added safety.

Now, neither Nizoral nor other dandruff shampoos are intended to be used as face washes. They do contain ingredients like fragrance that aren’t great for your skin, but, as someone with incredibly sensitive skin, I can also offer the opinion that Malassezia is worse. They’re also designed not to be actively harmful to your skin, since they end up there anyway if you use them to wash your hair.

Since I’d already started a breakout when I began this treatment, I couldn’t avoid dealing with Malassezia entirely. Nonetheless, this did make it a lot shorter and less severe. (Like, three to four days of a mild rash instead of two weeks of looking like I’d fallen into some kind of TMNT-style mutagenic ooze.) Also, no liver damage.

As much as I wish I didn’t have to do this, there’s sometimes no other choice. If I didn’t use clindamycin, I was at risk of death. This meant that I had to try to control the microorganisms it didn’t kill off, and bring myself back into balance. This approach helps reduce the number of pathogenic Malassezia and repopulate my body with all the little guys that’re supposed to be there.