Folliculitis


Overview
  • Folliculitis
    – Superficial bacterial infection of the hair follicles
    – Purulent material in the epidermis
     
  • Carbuncle
    – Coalescence of several inflamed follicles into a single inflammatory mass
    – Purulent drainage from multiple follicles
     
  • Furuncle (boil)
    – Infection of the hair follicle in which purulent material extends through the dermis into the subcutaneous tissue
    – Small abscess forms
    • Collection of pus within the dermis and deeper skin tissues

Etiologic agents
  • Usually attributable to Staph. aureus
  • Pseudomonas & aeromonas
    • Hot tubs, whirlpools, swimming pools
  • Candida species
    • Broad-spectrum antibiotics
    • Immunocompromised
    • Steroid Rx
  • Non-TB mycobacteria
History and Exam
  • Recent history of immersion in spa water
  • Darkly pigmented male with curly hair
  • Recent ingestion of drugs known to be associated with folliculitis
  • Recent history of shaving
  • Papules on one side of the face in the submaxillary area
  • Small, uniform papules and pustules
  • Background erythema
  • Umbilicated, flesh-colored papules
  • Alopecia/scalp scaling
  • Erythematous plaques with hemorrhagic crusts in a dermatomal distribution
     
Diagnostic Tests
  • Gram stain
  • Potassium hydroxide (KOH) preparation
  • Tzanck smear
  • Direct fluorescent antibody (DFA) assay
  • Tissue culture
  • Skin biopsy
     
Treatment
Uncomplicated superficial folliculitis, organism unknown
  • benzoyl peroxide topical : apply to the affected area(s) twice daily until lesion clearance
Recurrent/deep folliculitis due to methicillin-susceptible Staphylococcus aureus (MSSA) Primary Options
  • cephalexin : 250-500 mg orally four times daily for 10 days
  • dicloxacillin : 250 mg orally four times daily for 10 days

     
Adjunct - preventive measures

Skin should be washed regularly with antibacterial soaps.
  • benzoyl peroxide topical : apply to the affected area(s) twice daily until lesion clearance

     
Recurrent/deep folliculitis due to methicillin-resistant Staphylococcus aureus (MRSA) Primary Options
  • Clindamycin : 150-300 mg orally four times daily for 10 days

Secondary Options

  • trimethoprim/sulfamethoxazole : 160/800 mg orally twice daily for 10 days
  • Doxycycline : 100 mg orally twice daily for 10-14 days

Tertiary Options

  • linezolid : 600 mg orally twice daily for 10 days
  • vancomycin : 15 mg/kg intravenously twice daily for 5-7 days
Adjunct - MRSA carrier state eradication
  • Mupirocin topical : (2%) apply to nasal vestibules twice daily for 10 -14 days and
  • Chlorhexidine topical : (0.12%) apply all over body once daily for 5-7 days and
  • Rifampin : 600 mg orally once daily for 10-14 days
Gram-negative folliculitis Primary Options
  • benzoyl peroxide topical : apply to the affected area(s) twice daily until lesion clearance

Secondary Options

  • Ampicillin : 250 mg orally four times daily for 10-14 days

Adjunct

  • isotretinoin : 0.5 to 1 mg/kg orally twice daily for 16 weeks
hot tub folliculitis due to Pseudomonas aeruginosa infection Supportive care
  • Hot tub folliculitis is usually self-limited, and topical benzoyl peroxide wash may all that is required.
  • For refractory and exuberant cases of hot tub folliculitis, ciprofloxacin should be considered. GI discomfort, tinnitus, and blurred vision have been reported to be associated with ciprofloxacin administration.

Primary Options

  • benzoyl peroxide topical : apply to the affected area(s) twice daily until lesion clearance

Secondary Options

  • ciprofloxacin : 500 mg orally twice daily for 10 days
Dermatophytic folliculitis Systemic antifungals
Primary Options
  • Itraconazole : 100 mg orally twice daily for 14 days
  • Terbinafine : 250 mg orally once daily for 14 days

Adjunct

  • Ketoconazole topical : (2% shampoo) apply three to five times weekly until clearance; (2% cream) apply to the affected area(s) once or twice daily until clearance
  • Econazole topical : (1%) apply to the affected area(s) twice daily until clearance
Malassezia furfur (Pityrosporum folliculitis) Primary Options
  • ketoconazole topical : (2% shampoo) apply three to five times weekly until clearance; (2% cream) apply to the affected area(s) once or twice daily until clearance

Secondary Options

  • fluconazole : 100-200 mg orally once daily for 14-21 days
  • itraconazole : 100 mg orally twice daily for 14 days
Candida folliculitis Primary Options
  • Fluconazole : 100-200 mg orally once daily for 14-21 days
  • Itraconazole : 100 mg orally twice daily for 14 days
HSV folliculitis Primary Options
  • Acyclovir : 200 mg orally five times daily for 5-10 days
  • Valacyclovir : 500 mg orally three times daily for 5-10 days

Secondary Options

  • Famciclovir : 500 mg orally three times daily for 5-10 days
Demodex folliculorum folliculitis Primary Options
  • Permethrin topical : (5%) apply to the affected area(s) once daily at night for 7 days
  • Ivermectin : 200 micrograms/kg orally as a single dose
eosinophilic pustular folliculitis (Ofuji disease) Primary Option
  • Indomethacin : 25 mg orally (regular-release) twice daily until lesion clearance
  • Secondary Options
  • minocycline : 100 mg orally (regular-release) twice daily until lesion clearance
  • dapsone : 50-100 mg orally twice daily until lesion clearance
  • UV-B phototherapy: until lesion clearance

with pruritus - ADD Antipruritics and topical corticosteroids:

  • Pramoxine topical : (1%) apply to the affected area(s) three to four times daily when required
    -- AND --
  • Hydroxyzine : 25 mg orally once to four times daily until symptoms improve
    or

    Diphenhydramine : 25-50 mg orally every 4-6 hours when required, maximum 300 mg/day until symptoms improve
    -- AND --
  • Fluocinonide topical : (0.05%) apply sparingly to the affected area(s) once to four times daily until lesion clearance
HIV-associated eosinophilic folliculitis Primary Options
  • Treatment of HIV disease: consult specialist
    -- AND --
  • Betamethasone dipropionate topical : (0.05%) apply sparingly to the affected area(s) twice to four times daily until lesion clearance
    or

    Clobetasol topical : (0.05%) apply sparingly to the affected area(s) once to twice daily for up to 14 days, maximum 50 g/week until lesion clearance
    -- AND --
  • hydroxyzine : 25 mg orally once to four times daily until symptoms improve
    or

    Doxepin : 10 mg orally once daily at night when required until symptoms improve
    -- AND --
  • UV-B phototherapy: until lesion clearance
 




 









Hot-tub folliculitis