Folliculitis Empiric Therapy 

Updated: Feb 18, 2016
  • Author: Elizabeth K Satter, MD, MPH; Chief Editor: Michael Stuart Bronze, MD  more...
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Empiric Therapy Regimens

Empiric therapeutic regimens for folliculitis are outlined below, including those for superficial folliculitis, refractory or deep lesions, and Pseudomonas folliculitis.

The choice of empiric therapy is based on evidence-based medicine, which has identified the most common organism implicated in a particular clinical situation.

Superficial folliculitis

Prevention of infection plays a key role in therapy. For good hand washing with soap and water, wet hands with water, use plain soap, and rub hands together for 15-30 seconds. Pay special attention to the fingernails and between the fingers; wash all the way out to the wrists. Hands should be rinsed with clean water to remove residual soap and dried with a single-use towel (eg, paper towels). If soap and water are unavailable, alcohol-based hand sanitizers are a good alternative. Apply to the entire surface of hands and under the nails. When a sink is available, visibly soiled hands should be washed with soap and water.

For recurrent, uncomplicated, superficial folliculitis, antibacterial soaps or over-the-counter benzoyl peroxide washes and good hand washing are typically all that is needed. [1]

Refractory or deep lesions

To ease inflammation, warm compresses can be apply to the affected area for 10-20 minutes every few hours. Lesions that do not resolve with conservative therapy may require treatment with topical and/or oral antibiotics that cover gram-positive organisms.

If systemic antibiotics are indicated, coverage should include Staphylococcus aureus since it is the most common pathogen. Because this organism may be penicillin resistant, dicloxacillin 250 mg PO q6h for 7-10d or a cephalosporin such as cephalexin 250-500 mg q6h for 7-10d are the initial choices of therapy. [2, 3, 4, 5, 6]

If methicillin-resistant organisms are suspected, then confirmatory tissue culture should be performed and therapy directed to the susceptibility testing results. Most commonly, clindamycin, trimethoprim-sulfamethoxazole, minocycline, or linezolid are the drugs of choice.

Deep folliculitis (carbuncles and furuncles) is best approached with warm compresses, followed by incision and drainage once a conical pustular head develops. For recurrent and recalcitrant folliculitis, in addition to oral antibiotics, a search for a bacterial reservoir is important. Mupirocin ointment in the nasal vestibule twice a day for 5 days may eliminate the S aureus carrier state. Family members may also be nasal carriers of S aureus, and mupirocin ointment or rifampin at 600 mg/d orally for 10 days may eliminate the carrier state.

For patients in whom S aureus colonization is suspected, bleach baths or bleach soaks may be of benefit. [7] Briefly, for a full tub of water, use 1/2 cup of household nonconcentrated bleach, or, for a half-full tub, use 1/4 cup of bleach. Pour the bleach into the tub prior to entering, and soak in the tub for 5-10 minutes. Do not submerge the head, and be careful not to get water in the eyes. Wash off with clean water and pat dry. Light moisturizers can be used to prevent excess dryness. This can be done 2-3 times a week. If compresses are preferred, 1 teaspoon of bleach should be put in each gallon of water. Using a white wash cloth, soak the affected area for 5-10 minutes and follow with a clean-water rinse.

Pseudomonas folliculitis

In immunocompetent adults this condition is usually self-limited and spontaneously resolves in 2-14 days. To reduce bacterial colonization, as well as for symptomatic relief, either vinegar baths OR bleach baths can be used. For more specific information, the American Academy of Dermatology has complete patient directions for bleach bath therapy. See Eczema: Bleach bath therapy. [7]

Briefly, for a full tub of water, use 1/2 cup of household nonconcentrated bleach or vinegar, or for a 1/2 full tub use 1/4 cup of bleach or vinegar. Pour the bleach or vinegar into the tub prior to entering, and soak in the tub for 5-10 minutes. Do not submerge the head and be careful not to get water in the eyes. Wash off with clean water and pat dry. Light moisturizers can be used to prevent excess dryness. This can be done 2-3 times a week.

If compresses are preferred, 1 teaspoon of bleach or vinegar should be put in each gallon of water. Using a white wash cloth, soak the affected area for 5-10 minutes and follow with a clean water rinse. If treating a focal area, this can be done once to twice daily for symptomatic relief.

If itching is bothersome, an over-the-counter antihistamine, such as the following, can be used [8, 9] :

If the rash is more extensive, associated with fever, chills or enlarged lymph nodes then you should see a physician.

The pool or hot tub should be cleaned and disinfected. Do not share towels or razors with other members of the household.