Gram-Negative Folliculitis Clinical Presentation

  • Author: Mordechai M Tarlow, MD; Chief Editor: William D James, MD   more...
 
Updated: Jan 12, 2012
 

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 Associate, Department 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 Medical Association, American Society for MOHS Surgery, American Society of Cosmetic Dermatology and Aesthetic Surgery, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

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

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 and American Medical Association

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Terry L Barrett, MD  Clinical Professor of Dermatology and Pathology, University of Texas Southwestern School of Medicine; Director, ProPath Dermatopathology, Dallas, Texas

Terry L Barrett, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, College of American Pathologists, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD  Herman Beerman Associate 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 and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor; DLA Piper Consulting fee Consulting

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

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 and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

References

  1. Fulton JE Jr, McGinley K, Leyden J, Marples R. Gram-negative folliculitis in acne vulgaris. Arch Dermatol. Oct 1968;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. Jun 1973;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. Jun 2000;136(6):803. [Medline].

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

  5. Mulholland A, Yong-Gee S. A possible new cause of spa bath folliculitis: Aeromonas hydrophila. Australas J Dermatol. Feb 2008;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. Sep-Oct 2009;26(5):601-3. [Medline].

  7. Mulholland A, Yong-Gee S. A possible new cause of spa bath folliculitis: Aeromonas hydrophila. Australas J Dermatol. Feb 2008;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. May 2005;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. Sep-Oct 2010;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. Feb 1985;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. Apr 1982;6(4 Pt 2 Suppl):766-85. [Medline].

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

  14. Leyden JJ, McGinley KJ, Mills OH. Pseudomonas aeruginosa gram-negative folliculitis. Arch Dermatol. Oct 1979;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. Jun 1969;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. Apr 1999;38(4):270-4. [Medline].

  17. Noble WC. Gram-negative bacterial skin infections. Semin Dermatol. Dec 1993;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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