Folliculitis

Uncomplicated folliculitis is self-limited and usually does not require medical intervention. While the causative organism is unknown, Staphylococcus aureus is likely to be involved.

Simple preventative measures, such as use of antibacterial soaps or wearing loose clothing, may be all that is required.

Skin should be washed regularly with antibacterial soaps.

Benzoyl peroxide preparations have broad-spectrum antimicrobial activities and can bleach clothing and linens. Skin should therefore be allowed to dry completely before coming into contact with clothing. Loose, porous, lightweight clothing should be worn.

A dry, cool environment can help reduce recurrence. Meticulous shaving techniques should be practiced. For men with recurrent and chronic folliculitis in the beard region, careful shaving techniques may help decrease the recurrence of folliculitis. The affected area should be washed with a non-abrasive antibacterial soap and a washcloth.

Cephalosporins are penicillinase-resistant antibiotics that are commonly used to treat S aureus soft tissue infections, including S aureus folliculitis. The most commonly used agent is cefalexin, a first-generation cephalosporin.

Dicloxacillin is a penicillinase-resistant penicillin that is also commonly used for S aureus folliculitis. Dosage needs to be adjusted for both drugs for patients with renal impairment.

Antibiotics may decrease the efficacy of oral contraceptives.

Additional treatment recommended for SOME patients in selected patient group

Skin should be washed regularly with antibacterial soaps.

Benzoyl peroxide preparations have broad-spectrum antimicrobial activities and can bleach clothing and linens. Skin should therefore be allowed to dry completely before coming into contact with clothing. Loose, porous, lightweight clothing should be worn.

A dry, cool environment can help reduce recurrence. Meticulous shaving techniques should be practiced. For men with recurrent and chronic folliculitis in the beard region, careful shaving techniques may help decrease the recurrence of folliculitis. The affected area should be washed with a non-abrasive antibacterial soap and a washcloth.

Oral clindamycin, trimethoprim/sulfamethoxazole, minocycline, and linezolid are used to treat MRSA folliculitis. Intranasal mupirocin, chlorhexidine wash, and rifampicin can be used to eradicate MRSA carrier state.

Clindamycin is used for the treatment of MRSA. Oral clindamycin is associated with severe and potentially fatal colitis. Dosage adjustment is recommended in patients with severe hepatic impairment.

Trimethoprim/sulfamethoxazole is sometimes used for the treatment of MRSA, but the risks of developing Stevens-Johnson syndrome and toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, and aplastic anaemia must be considered.

If an MRSA species shows sensitivity to minocycline, the drug can be used to treat MRSA folliculitis. As with other tetracyclines, minocycline may decrease the effectiveness of oral contraceptive medicine.

Although rarely used in practice, linezolid is reserved for the treatment of serious bacterial infections by multiresistant organisms, such as MRSA, when other antibiotics have failed. The development of thrombocytopaenia and serotonin syndrome has been linked to linezolid use. If a patient requiring linezolid is on an antidepressant, it should be discontinued while on linezolid and the patient monitored for serotonin syndrome for 24 hours after the last dose of linezolid is given.

If the area involved is widespread or persistent, systemic antibiotics may be indicated. Intravenous vancomycin has long been the treatment of choice for locally deep or systemic MRSA infections. Recommendations on appropriate use and preventing/controlling spread of vancomycin resistance should be considered. CDC: methicillin-resistant Staphylococcus aureus (MRSA) Opens in new window

Additional treatment recommended for SOME patients in selected patient group

In patients with recurrent MRSA folliculitis, measures to decrease MRSA colonisation or eradicate MRSA carrier state have been studied. The application of mupirocin to the nasal vestibule has been advocated by some clinicians.

Chlorhexidine wash has been shown to decrease colonisation of MRSA;[47]Wendt C, Schinke S, Württemberger M, et al. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol. 2007 Sep;28(9):1036-43. http://www.ncbi.nlm.nih.gov/pubmed/17932823?tool=bestpractice.com however, by itself, chlorhexidine wash does not appear to eradicate MRSA carrier state.

Studies have found that rifampicin can eradicate MRSA carrier state in some patients;[48]Falagas ME, Bliziotis IA, Fragoulis KN. Oral rifampin for eradication of Staphylococcus aureus carriage from healthy and sick populations: a systematic review of the evidence from comparative trials. Am J Infect Control. 2007 Mar;35(2):106-14. http://www.ncbi.nlm.nih.gov/pubmed/17327190?tool=bestpractice.com however, its use has been associated with the development of antimicrobial resistance during and after treatment.

Gram-negative folliculitis is typically seen in patients undergoing long-term oral antibiotic therapy, and it is associated with Klebsiella, Enterobacter, or Proteus infections.[39]Stulberg DL, Penrod MA, Blatny RA. Common bacterial skin infections. Am Fam Physician. 2002 Jul 1;66(1):119-24. https://www.aafp.org/afp/2002/0701/p119.html http://www.ncbi.nlm.nih.gov/pubmed/12126026?tool=bestpractice.com Current antibiotics for acne should be discontinued and the skin washed with benzoyl peroxide preparations.

Alternative antibiotic treatment may be considered, guided by microbiology.

Additional treatment recommended for SOME patients in selected patient group

For exuberant or recalcitrant cases, consider referring to dermatology for oral isotretinoin.[41]Neubert U, Plewig G, Ruhfus A. Treatment of gram-negative folliculitis with isotretinoin. Arch Dermatol Res. 1986;278(4):307-13. http://www.ncbi.nlm.nih.gov/pubmed/2943234?tool=bestpractice.com [42]Leyden JJ, Marples RR, Mills OH Jr, et al. Gram-negative folliculitis - a complication of antibiotic therapy in acne vulgaris. Br J Dermatol. 1973 Jun;88(6):533-8. http://www.ncbi.nlm.nih.gov/pubmed/4268682?tool=bestpractice.com

Isotretinoin is a well-documented teratogen, and should be taken only when appropriate contraceptive measures are in place. In the UK, a revised Pregnancy Prevention Programme for isotretinoin was implemented in 2005, Oral retinoids: pregnancy prevention - reminder of measures to minimise teratogenic risk Opens in new window while in the US patients should be registered with the iPledge programme. iPledge Opens in new window Isotretinoin commonly causes severe dryness of skin and mucous membranes. It has been associated with the development of pseudotumour cerebri, hyperlipidaemia, elevated liver function enzymes, and cataracts.

Hot tub folliculitis is usually self-limited, and topical benzoyl peroxide may be all that is required.

For hot tub folliculitis due to Pseudomonas aeruginosa, the eruption is generally self-limited and does not require systemic antibiotic treatment.[39]Stulberg DL, Penrod MA, Blatny RA. Common bacterial skin infections. Am Fam Physician. 2002 Jul 1;66(1):119-24. https://www.aafp.org/afp/2002/0701/p119.html http://www.ncbi.nlm.nih.gov/pubmed/12126026?tool=bestpractice.com However, if the eruption is severe or occurs in an immunocompromised host, ciprofloxacin (a fluoroquinolone) may be used with caution.

Fluoroquinolones should be used with caution. Adverse effects may include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects. Their use has been restricted in certain indications.[43]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. March 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products In addition to these restrictions, the US Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[44]US Food and Drug Administration. FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. July 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-reinforces-safety-information-about-serious-low-blood-sugar-levels-and-mental-health-side [45]US Food and Drug Administration. FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. December 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics

Systemic therapy with oral itraconazole or terbinafine is recommended for dermatophytic folliculitis. There is a wide range of practice patterns with regards to dosing and frequency of systemic antifungal therapy. Some clinicians prefer continuous oral antifungal therapy for 2 to 3 weeks. Others prefer monthly pulse therapy.

Both oral itraconazole and terbinafine are associated with elevated liver function enzymes in some cases. Terbinafine use has been associated with rare cases of fulminant liver failure.

Additional treatment recommended for SOME patients in selected patient group

Topical antifungal agents (such as ketoconazole or econazole) are less effective but may be used as an adjunctive to oral antifungal therapy.

Pityrosporum folliculitis responds initially to topical antifungal agents, such as ketoconazole shampoo and cream, but relapses often occur. For these recurrent cases, systemic antifungal agents are recommended, such as fluconazole or itraconazole.

Fluconazole use is associated with elevated liver function enzymes, exfoliative dermatitis, QT prolongation, and endocrine effects (breast tenderness, alopecia, and impotence in males). Fluconazole can alter the metabolism of some medicine through its effect on P450 enzymes.

Itraconazole use is associated with elevated liver function enzymes and hypertension. Itraconazole can alter the metabolism of some medicine through its effect on P450 enzymes.

For fungal folliculitis with Candida species, systemic antifungals such as fluconazole or itraconazole are most effective.

Fluconazole use is associated with elevated liver function enzymes, exfoliative dermatitis, QT prolongation, and endocrine effects (breast tenderness, alopecia, and impotence in males). Fluconazole can alter the metabolism of other medicine through its effect on P450 enzymes.

Itraconazole use is associated with elevated liver function enzymes and hypertension. Itraconazole can alter the metabolism of other medicine through its effect on P450 enzymes.

Treat herpes simplex virus (HSV) folliculitis with oral antiviral therapy at the earliest sign of infection. Aciclovir or valaciclovir are recommended. Famciclovir can be given as a second-line option.

Aciclovir administration has been associated with renal failure (usually with intravenous administration), thrombotic thrombocytopenic purpura in immunocompromised patients, and encephalopathic changes.

Valaciclovir is a prodrug of aciclovir with better oral bioavailability. Erythema multiforme has been reported with famciclovir use.

Demodex folliculitis can be treated with topical application of permethrin cream or a single dose of ivermectin.

Application of permethrin cream has been associated with itching, tingling, and erythema.

Single dose of ivermectin is generally well tolerated, although some patients may experience gastrointestinal discomfort. Rare, serious adverse effects include visual changes, weakness, confusion, and seizures.

First-line treatment of drug-induced folliculitis is stopping and avoiding the offending agent. If a patient is unable to stop the drug, topical tretinoin is an option as drug-induced folliculitis is usually acneiform in nature.[29]Luelmo-Aguilar J, Santandreu MS. Folliculitis: recognition and management. Am J Clin Dermatol. 2004;5(5):301-10. http://www.ncbi.nlm.nih.gov/pubmed/15554731?tool=bestpractice.com

In some patients with HIV-associated eosinophilic folliculitis, treatment of the underlying HIV infection with antiretroviral therapy leads to resolution of symptoms.

In others where there is no improvement as a result of antiretroviral therapy, oral antihistamines and potent topical corticosteroids, in combination with UV-B phototherapy, may be necessary.

This is self-limiting and runs a benign course.

Eosinophilic pustular folliculitis in infancy associated with pruritus can be treated with topical corticosteroids and oral antihistamines during flares.

Because of children's increased body surface area to weight ratio, they are at increased risk of systemic effects from topical corticosteroids, and lower-potency formulations should be used whenever possible, usually for 1 to 2 weeks. Employing the lowest potency formulation that can be used to successfully treat a patient's disease will help to minimize side effects.