Medical Care
Before a treatment plan is devised, it is important to consider the etiology of the folliculitis, severity, and distribution of the lesions. For uncomplicated superficial folliculitis, use of antibacterial soaps and good hand-washing techniques may be all that is needed. Lesions that are more inflamed usually respond well to warm compresses with or without the use of a topical antimicrobial agent. For refractory or deep lesions with a suspected infectious etiology, empiric treatment with oral antibiotics that cover gram-positive organisms should be considered. For patients who do not improve with a standard course of antibiotics, other causes of folliculitis must be investigated.
If systemic antibiotics are indicated, coverage should include S aureus since it is the most common pathogen. Because this organism may be penicillin resistant, dicloxacillin or a cephalosporin are the initial choices of therapy. Methicillin-resistant organisms are becoming more common, and treatment may require clindamycin, trimethoprim-sulfamethoxazole, minocycline, or linezolid.
Deep folliculitis 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.
Medical care for the other types of folliculitis is as follows:
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Pseudomonas folliculitis is usually self-limited and does not require treatment; however, if the patient is immunocompromised or the lesions are persistent, oral ciprofloxacin may be given.
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Eosinophilic pustular folliculitis (Ofuji disease) does not respond to systemic antibiotics. First line treatment is indomethacin (50 mg/day). Other therapies include UVB phototherapy, minocycline, or dapsone. [25]
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Pityrosporum folliculitis initially responds to topical antifungals such as ketoconazole cream or shampoo but is often associated with relapses. For relapses, systemic antifungals should be tried.
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Gram-negative folliculitis that arises as a complication of chronic antibiotic use is best approached by discontinuing the implicated antibiotic and administering oral trimethoprim-sulfamethoxazole. Use of benzoyl peroxide washes may also be beneficial.
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Herpetic folliculitis responds to valacyclovir, famciclovir, or acyclovir.
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Papulopustular eruption associated with epidermal growth factor receptor inhibitors is self-limited and resolves with cessation of chemotherapy. In patients requiring treatment, topical antibiotics, topical corticosteroids or oral antibiotics, particularly tetracyclines, can be administered.
Consultations
The patient's primary care provider can usually diagnose and treat uncomplicated cases of folliculitis, but for those cases that are persistent or result in scarring, a dermatologist should be consulted.
Diet
Because folliculitis is more common in individuals who are obese, weight reduction may be helpful.
Activity
If the patient equates episodes of folliculitis to wearing a wet suit or other sports gear, these items should be cleaned with antimicrobial soaps and dried well.
Prevention
Avoid shaving irritated skin for 1 month or until all lesions have resolved. To prevent future lesions, avoid close shaving and change disposable razors daily. In addition, periodically soak electric razor heads in 70% alcohol or diluted bleach for 1 hour to eliminate overgrowth of bacteria or fungi.
Good personal hygiene, including bathing, hand washing, and keeping nails short and clean, reduces the risk of folliculitis. Wearing loose rather than snug-fitting clothing helps reduce friction.
In cases of acute infectious folliculitis, launder towels, washcloths, and sheets frequently and do not share them with other family members.
Hot tubs should be cleaned regularly and appropriately chlorinated.
Long-Term Monitoring
Arrange a follow-up visit within 2 weeks to check response to treatment.
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A 22-month-old boy with a staphylococcal folliculitis on the buttocks. The lesions have been excoriated. Diaper occlusion may have been related to onset of the rash.
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A 30-year-old woman with hot tub folliculitis. She had used a hot tub 2 days prior, wearing a bikini-style bathing suit.
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Pseudomonas folliculitis. Courtesy of Hon Pak, MD.
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Superficial folliculitis with neutrophils concentrated in the upper aspect of the follicle
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Perifolliculitis, showing inflammatory cells surrounding the follicle,
