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Gram-Negative Folliculitis Clinical Presentation

  • Author: Mordechai M Tarlow, MD; Chief Editor: William D James, MD  more...
 
Updated: Mar 27, 2014
 

History

A history is helpful in suggesting the diagnosis of gram-negative folliculitis.

Patients usually have been receiving a course of antibiotics for a prolonged period. Patients with gram-negative folliculitis may present with 1 of 2 histories as follows:

  • A history of apparent acne, usually of the nodulocystic form, may be present. The acne has not been responding to antimicrobial therapy or other therapy.
  • A history of acne that has responded well to therapy and suddenly flares may be present. This exacerbation may occur a few days following cessation of an effective antibiotic or a few days following institution of a new antibiotic.
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Physical

Because gram-negative folliculitis usually occurs in patients with existing acne, the development of this new process is often mistaken as an exacerbation of acne.

  • Morphology of the lesions
    • Type 1 (approximately 80% of patients) - Superficial pustular lesions without comedones
    • Type 2 (approximately 20% of patients) - Deep, nodular, and cystic lesions
  • Distribution of the lesions - Extending from the infranasal area to the chin and the cheeks
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Causes

Systemic antibiotics, such as tetracyclines, can alter the nasal flora. The resultant overgrowth of gram-negative bacteria can lead to folliculitis.

  • Type 1 lesions are usually associated with a lactose-fermenting, gram-negative rod, including Klebsiella, Escherichia, and Serratia species. Cases associated with Citrobacter species, another organism of the Enterobacteriaceae family, have also been described.[3, 4]
  • Type 2 lesions are associated with Proteus species. These species are motile and, thus, have the ability to invade more deeply, producing the large suppurative abscesses that result in deeper cystic lesions.
  • Folliculitis caused by Pseudomonas organisms is typically associated with immersion in hot tubs and swimming pools, resulting in a generalized folliculitis.[5] Aeromonas hydrophila has also been associated with water sources, including an inflatable pool.[6, 7] Home spas have also been implicated in causing gram-negative folliculitis. In the reported patients who were swimmers, a sudden unmanageable flare-up of facial acne associated with chronic bilateral otitis externa was reported. A case of Acinetobacter baumannii folliculitis of the face, neck, arms, and upper part of the trunk has been reported in a patient with AIDS.[8]
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Contributor Information and Disclosures
Author

Mordechai M Tarlow, MD Clinical Assistant Professor of Dermatology, University of Pennsylvania School of Medicine

Mordechai M Tarlow, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, American College of Aesthetic and Cosmetic Physicians; American Society of Aesthetic/Cosmetic Physicians, American Medical Association, Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Michael Wiederkehr, MD Consulting Staff, Livingston Dermatology Associates; Consulting Staff, Comprehensive Dermatology and Laser Center

Michael Wiederkehr, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association

Disclosure: Nothing to disclose.

Sofia Piela, MD Head, Department of Dermatology, Rzeszow Regional Health Center, Poland

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Rosalie Elenitsas, MD Herman Beerman Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Andrea Leigh Zaenglein, MD Professor of Dermatology and Pediatrics, Department of Dermatology, Hershey Medical Center, Pennsylvania State University College of Medicine

Andrea Leigh Zaenglein, MD is a member of the following medical societies: American Academy of Dermatology, Society for Pediatric Dermatology

Disclosure: Received consulting fee from Galderma for consulting; Received consulting fee from Valeant for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Anacor for consulting; Received grant/research funds from Stiefel for investigator; Received grant/research funds from Astellas for investigator; Received grant/research funds from Ranbaxy for other; Received consulting fee from Ranbaxy for consulting.

References
  1. Fulton JE Jr, McGinley K, Leyden J, Marples R. Gram-negative folliculitis in acne vulgaris. Arch Dermatol. 1968 Oct. 98(4):349-53. [Medline].

  2. Leyden JJ, Marples RR, Mills OH Jr, Kligman AM. Gram-negative folliculitis--a complication of antibiotic therapy in acne vulgaris. Br J Dermatol. 1973 Jun. 88(6):533-8. [Medline].

  3. Chastain MA. A cycle: recurrent gram-negative folliculitis with Citrobacter diversus (koseri) following eradication of recurrent staphylococcal pyoderma. Arch Dermatol. 2000 Jun. 136(6):803. [Medline].

  4. Mostafa WZ. Citrobacter freundii in gram-negative folliculitis. J Am Acad Dermatol. 1989 Mar. 20(3):504-5. [Medline].

  5. Mulholland A, Yong-Gee S. A possible new cause of spa bath folliculitis: Aeromonas hydrophila. Australas J Dermatol. 2008 Feb. 49(1):39-41. [Medline].

  6. Julia Manresa M, Vicente Villa A, Gene Giralt A, Gonzalez-Ensenat MA. Aeromonas hydrophila folliculitis associated with an inflatable swimming pool: mimicking Pseudomonas aeruginosa infection. Pediatr Dermatol. 2009 Sep-Oct. 26(5):601-3. [Medline].

  7. Mulholland A, Yong-Gee S. A possible new cause of spa bath folliculitis: Aeromonas hydrophila. Australas J Dermatol. 2008 Feb. 49(1):39-41. [Medline].

  8. Bachmeyer C, Landgraf N, Cordier F, Lemaitre P, Blum L. Acinetobacter baumanii folliculitis in a patient with AIDS. Clin Exp Dermatol. 2005 May. 30(3):256-8. [Medline].

  9. Palit A, Inamadar AC. Current concepts in the management of bacterial skin infections in children. Indian J Dermatol Venereol Leprol. 2010 Sep-Oct. 76(5):476-88. [Medline].

  10. Böni R, Nehrhoff B. Treatment of gram-negative folliculitis in patients with acne. Am J Clin Dermatol. 2003. 4(4):273-6. [Medline].

  11. James WD, Leyden JJ. Treatment of gram-negative folliculitis with isotretinoin: positive clinical and microbiologic response. J Am Acad Dermatol. 1985 Feb. 12(2 Pt 1):319-24. [Medline].

  12. Plewig G, Nikolowski J, Wolff HH. Action of isotretinoin in acne rosacea and gram-negative folliculitis. J Am Acad Dermatol. 1982 Apr. 6(4 Pt 2 Suppl):766-85. [Medline].

  13. Blankenship ML. Gram-negative folliculitis. Follow-up observations in 20 patients. Arch Dermatol. 1984 Oct. 120(10):1301-3. [Medline].

  14. Leyden JJ, McGinley KJ, Mills OH. Pseudomonas aeruginosa gram-negative folliculitis. Arch Dermatol. 1979 Oct. 115(10):1203-4. [Medline].

  15. Marples RR, Fulton JE, Leyden J, McGinley KJ. Effect of antibiotics on the nasal flora in acne patients. Arch Dermatol. 1969 Jun. 99(6):647-51. [Medline].

  16. Neubert U, Jansen T, Plewig G. Bacteriologic and immunologic aspects of gram-negative folliculitis: a study of 46 patients. Int J Dermatol. 1999 Apr. 38(4):270-4. [Medline].

  17. Noble WC. Gram-negative bacterial skin infections. Semin Dermatol. 1993 Dec. 12(4):336-41. [Medline].

  18. Simjee S, Sahm DF, Soltani K, Morello JA. Organisms associated with gram-negative folliculitis: in vitro growth in the presence of isotretinoin. Arch Dermatol Res. 1986. 278(4):314-6. [Medline].

  19. Tan HH. Antibacterial therapy for acne: a guide to selection and use of systemic agents. Am J Clin Dermatol. 2003. 4(5):307-14. [Medline].

  20. Tarlow MM, Piela Z, Schwartz RA. Gram-negative folliculitis - a diagnostic challenge. Dermatologia Kliniczna. 2002. 4:7-9.

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Pseudomonas folliculitis. Courtesy of Hon Pak, MD.
 
 
 
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