Folliculitis Empiric Therapy

Updated: Nov 08, 2022
  • Author: Elizabeth K Satter, MD, MPH; Chief Editor: Michael Stuart Bronze, MD  more...
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Empiric Therapy Regimens

Empiric therapeutic regimens for superficial and deep folliculitis, as well as Pseudomonas folliculitis, are outlined below.

The choice of empiric therapy is determined based upon the most common organisms that are usually found in a particular clinical situation.

Also see Folliculitis Organism-Specific Therapy.

Superficial folliculitis

Good hand washing plays an essential role in prevention. When a sink is available, visibly soiled hands should be washed 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.

Most cases of uncomplicated superficial folliculitis will spontaneously resolve in a few days and no treatment is required other than good skin hygiene and use of antibacterial soap.  For more extensive superficial folliculitis, over-the-counter benzoyl peroxide washes alone, or along with 1% clindamycin gel or lotion is all that is needed. [1]   However, to date there are no clinical trials that have compared placebo with topical antibiotics or topical antiseptics to establish the efficacy of one regimen over another.  [11]

Deep folliculitis (boil, carbuncle, furuncle)

Deep folliculitis (carbuncles and furuncles) is best approached using warm compresses, which should be applied to the affected area for 10-20 minutes and repeated every few hours. Compresses should be warm, but not excessively hot, since burns can occur. Warm compresses can reduced the inflammation or lead to the development of a conical pustular head that spontaneously ruptures and drains. If, however, the area enlarges and becomes extremely tense and painful without spontaneously rupturing, then an incision and drainage will need to be performed by a physician.

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.

For recurrent and recalcitrant folliculitis, in addition to oral antibiotics, a search for a bacterial reservoir is important (nasal culture, and/or culture of axilla and umbilicus). Mupirocin ointment applied in the nasal vestibule twice a day for 5 days may help eliminate the S aureus carrier state; however, some patients with recurrent/persistent folliculitis may need to take rifampin at 600 mg/d orally for 10 days in addition to the above oral antibiotics and topical mupirocin. Family members can also be nasal carriers of S aureus and should also be swabbed and treated if found to be carriers.

For patients in whom S aureus colonization is suspected, bleach baths or bleach soaks may be beneficial. [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. Immediately after the bath, wash off with clean water and pat dry. Light moisturizers can be used to prevent excess dryness. This should only be done at most 2-3 times a week.

If the folliculitis is focal and bleach compresses are preferred, 1 teaspoon of bleach or vinegar should be put in each gallon of water. The patient should then use a white wash cloth dampened in the diluted bleach solution and soak the affected area for 5-10 minutes. This should then be followed with a clean water rinse. If only a focal area is treated, the compresses can be used once to twice daily for symptomatic relief, and a light moisturizer can be applied after the clean water rinse to prevent excessive dryness. 

If itching is bothersome, over-the-counter anti-itch creams that contain pramoxine and/or menthol and camphor can be used. If itching is still bothersome, over-the-counter antihistamines can be added, such as the following [8, 9] :

If the rash is more extensive, or associated with fever, chills and/or enlarged lymph nodes, then the patient should consult a physician.

Pseudomonas aeruginosa found in public swimming pools has been found to be broadly antibiotic-resistant. Among oral antibiotics, P aeruginosa is most commonly sensitive to ciprofloxacin. [10]  

If the folliculitis occurred after using a pool or hot tub, then it should be cleaned and disinfected. Do not share towels or razors with other members of the household.