eMedicine Specialties > Dermatology > Bacterial Infections
Gram-Negative Folliculitis: Treatment & Medication
Updated: Nov 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treatment of gram-negative folliculitis includes the use of isotretinoin and systemic antibiotics.
- Isotretinoin offers the most effective cure for gram-negative folliculitis.8,9,10
- It is a synthetic beta-carotene derivative that is highly effective when used in patients with severe nodulocystic acne unresponsive to conventional therapy. Studies in patients with gram-negative folliculitis have demonstrated effective eradication of facial lesions and nasal carriage with isotretinoin, with an average clearance time of approximately 2-3 months. A low incidence of recurrence has been reported with this therapy.
- Isotretinoin has no antibiotic effect against the organisms causing gram-negative folliculitis.
- Several mechanisms have been proposed for its action, including sebum suppression, because all patients with this disease have severe seborrhea prior to isotretinoin treatment, and drying out of the mucous membranes, including the nasal mucosa, which is the reservoir for the organisms.
- Systemic antibiotics were the mainstay of therapy for gram-negative folliculitis prior to the development of isotretinoin; the choice of antibiotic was dictated by antibiotic sensitivities. Topical therapy rarely works.
- The most effective antibiotics have come from the bacteriostatic group, which includes ampicillin and trimethoprim-sulfamethoxazole.
- Reports have conflicted concerning the degree to which these medications can eradicate the carriage of gram-negative organisms and induce remission. Most studies describe recurring infection after therapy is discontinued, making antibiotic use largely a suppressive modality.
- Gram-negative folliculitis caused by Pseudomonas organisms in whirlpools usually subsides spontaneously within 10 days without recurrence. In patients with facial folliculitis caused by Pseudomonas organisms associated with acne vulgaris, the infection clears when the source of the organism, external otitis, is cured. Acinetobacter baumannii folliculitis in the setting of AIDS has responded to intravenous treatment with ticarcillin-clavulanic acid.
- Most patients have ordinary acne in addition to gram-negative folliculitis. Once the folliculitis has responded, residual acne must be treated by other methods, including retinoic acid, benzoyl peroxide, cryotherapy, and other therapies.
- Gram-negative folliculitis is relatively uncommon, and the general benefit from antibiotics far outweighs the occasional complication of folliculitis.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Retinoids
These agents modulate keratinocyte differentiation and decrease sebum production.
Isotretinoin (Accutane)
Oral agent that treats serious dermatologic conditions, isotretinoin is synthetic 13-cis isomer of naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to beta-carotene. Decreases sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization.
A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.
Female patients must sign an informed consent that they will use contraceptives during treatment course and for 30 d after discontinuing therapy.
Adult
0.5-1 mg/kg PO qd
Pediatric
Not established
Toxicity may occur with beta-carotene coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; may reduce plasma levels of carbamazepine
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May decrease night vision; inflammatory bowel disease may occur; may be associated with development of hepatitis; occasional exaggerated healing response of folliculitis and acne (excessive granulation with crusting) may occur; patients with diabetes may experience problems controlling blood sugar levels; advise patients to avoid exposure to UV light or sunlight until tolerance is achieved; discontinue if rectal bleeding, abdominal pain, or severe diarrhea occur
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.
Ampicillin (Principen, Omnipen, Marcillin)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Adult
250-500 mg PO q6h
500-1500 mg IM q4-6h
500-3000 mg IV q4-6h; not to exceed 12 g/d
Pediatric
50-100 mg/kg/d PO divided q4-6h
100-400 mg/kg/d IM/IV divided q4-6h
Probenecid and disulfiram elevate levels; allopurinol decreases effects and worsens ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Trimethoprim and sulfamethoxazole (Bactrim, Septra)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
160 mg TMP/800 mg SMZ PO q12h
Pediatric
<2 months: Do not administer
>2 months: 15-20 mg TMP/kg/d PO tid/qid
May increase PT levels when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenic purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or signs of adverse reaction; monitor CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer leucovorin 5-15 mg/d); caution in folate deficiency (eg, patients who drink excessive amounts of alcohol, elderly patients, patients receiving anticonvulsant therapy, or patients with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
More on Gram-Negative Folliculitis |
| Overview: Gram-Negative Folliculitis |
| Differential Diagnoses & Workup: Gram-Negative Folliculitis |
 Treatment & Medication: Gram-Negative Folliculitis |
| Follow-up: Gram-Negative Folliculitis |
| References |
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References
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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].
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].
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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].
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].
Noble WC. Gram-negative bacterial skin infections. Semin Dermatol. Dec 1993;12(4):336-41. [Medline].
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].
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].
Tarlow MM, Piela Z, Schwartz RA. Gram-negative folliculitis - a diagnostic challenge. Dermatologia Kliniczna. 2002;4:7-9.
Further Reading
Keywords
gram-negative folliculitis, acne, acne vulgaris, rosacea, prolonged antibiotic therapy, acne treatment complications species, species, species, Citrobacter species, species,
