Approach Considerations

As history is the primary method by which a diagnosis is made, advancements and increases acceptance of direct-to-consumer telemedicine and apps have resulted in this condition being a particular diagnosis at risk of being missed. Additional consideration should be given to patients presenting with self-diagnosed and treated acne with flare for gram-negative folliculitis.^[16]

Laboratory Studies

The diagnosis of gram-negative folliculitis can often be made based on the history and the physical examination findings alone. However, confirmation with Gram stain and culture is recommended.

In confirming the diagnosis with Gram stain and culture, use special care in culturing. Gram-negative organisms are sensitive to desiccation; samples must be taken quickly and cultured as soon as possible. The pustule that is sampled should also be fresh. A small pustule on an erythematous base is preferable for culturing purposes.

Culture pustules in any patient with acne who is in their late teens or older and has been on long-term antibiotics and develops a pustular form of the disease.

Gram-negative organisms cannot be recovered from every pustule but will be found on cultures of the anterior nares.

Selective medium-containing dyes, such as methylene blue, allow selective growth of gram-negative organisms while inhibiting growth of gram-positive organisms.

The organisms that produce colonies on eosin-methylene blue agar are classified as either lactose-fermenting gram-negative rods or Proteus species by their cultural characteristics and their ability to ferment lactose. Lactose-fermenting, gram-negative rods produce small, dark, discreet, metallic colonies. Proteus species produce rapidly spreading, translucent, and odorous colonies.

In patients with facial folliculitis that presents a diagnostic challenge, a potassium hydroxide mount (10-20% potassium hydroxide is used to stain a sample on a slide and look for possible fungal elements) and a skin biopsy specimen may be of value.

Medication

Fulton JE Jr, McGinley K, Leyden J, Marples R. Gram-negative folliculitis in acne vulgaris. Arch Dermatol. 1968 Oct. 98(4):349-53. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Resneck JS Jr, Abrouk M, Steuer M, Tam A, Yen A, Lee I, et al. Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease. JAMA Dermatol. 2016 Jul 1. 152 (7):768-75. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Böni R, Nehrhoff B. Treatment of gram-negative folliculitis in patients with acne. Am J Clin Dermatol. 2003. 4(4):273-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Zhou F, Lin S, Zhang J, Kong Z, Tan BK, Hamzah SS, et al. Enhancement of photodynamic bactericidal activity of curcumin against Pseudomonas Aeruginosa using polymyxin B. Photodiagnosis Photodyn Ther. 2022 Mar. 37:102677. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mostafa WZ. Citrobacter freundii in gram-negative folliculitis. J Am Acad Dermatol. 1989 Mar. 20(3):504-5. [QxMD MEDLINE Link].
Livani F, Kabir S. Gram-negative folliculitis caused by Morganella morganii. JAAD Case Rep. 2019 Jun. 5 (6):558-559. [QxMD MEDLINE Link].
Mulholland A, Yong-Gee S. A possible new cause of spa bath folliculitis: Aeromonas hydrophila. Australas J Dermatol. 2008 Feb. 49(1):39-41. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mulholland A, Yong-Gee S. A possible new cause of spa bath folliculitis: Aeromonas hydrophila. Australas J Dermatol. 2008 Feb. 49(1):39-41. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Resneck JS Jr, Abrouk M, Steuer M, Tam A, Yen A, Lee I, et al. Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease. JAMA Dermatol. 2016 Jul 1. 152 (7):768-75. [QxMD MEDLINE Link].
Tarlow MM, Piela Z, Schwartz RA. Gram-negative folliculitis - a diagnostic challenge. Dermatologia Kliniczna. 2002. 4:7-9.

Media Gallery

Pseudomonas folliculitis. Courtesy of Hon Pak, MD.

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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, The Scientific Research Honor Society

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, American Medical Association

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

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.

Gram-Negative Folliculitis Workup

Approach Considerations

Laboratory Studies

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