Approach
Uncomplicated folliculitis is self-limited and usually does not require medical intervention. However, recurrent infectious folliculitis requires medical attention.
After the aetiological micro-organism is determined through laboratory work-up, antibiotic therapy is guided by target organisms and culture sensitivities.
Severe cases of folliculitis can evolve into abscesses, which are treated with antibiotics and incision and drainage.[38]
Uncomplicated superficial folliculitis, organism unknown
While the causative organism is unknown, Staphylococcus aureus is likely to be involved. For uncomplicated superficial folliculitis, simple preventative measures, such as use of antibacterial soaps or wearing loose clothing, may be all that is required. Regular washing with antibacterial soap and/or benzoyl peroxide preparations in hair-bearing regions may be helpful in reducing the occurrence of folliculitis. Wearing loose, porous clothing and being in a cool, dry environment is also helpful.
Staphylococcus aureus
Anti-staphylococcal therapy is guided by culture sensitivities. In S aureus folliculitis, the organism can be either susceptible or resistant to methicillin on sensitivity testing. Targeted antibiotic therapy is chosen based on culture sensitivity results. For example, penicillinase-resistant penicillins, such as dicloxacillin, or a cephalosporin, are generally used since S aureus is often penicillin-resistant.[39] For methicillin-resistant S aureus species, clindamycin, trimethoprim/sulfamethoxazole, tetracyclines, or linezolid are recommended treatments.
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. If a patient is found to be a carrier for MRSA through nasal, groin, or axillary cultures, in the absence of clinically active infection, the patient can be treated for staph elimination with topical antibiotic therapies, such as intranasal topical mupirocin application.[40] CDC: methicillin-resistant Staphylococcus aureus (MRSA) Opens in new window
Gram-negative
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] Current antibiotics for acne should be discontinued and the skin washed with benzoyl peroxide preparations. Alternative antibiotic treatment may be considered, guided by microbiology. For exuberant or recalcitrant cases, consider referring to dermatology for oral isotretinoin.[41][42]
For hot tub folliculitis due to Pseudomonas aeruginosa, the eruption is generally self-limited and does not require systemic antibiotic treatment.[39] However, if the eruption is severe or occurs in an immunocompromised host, ciprofloxacin (a fluoroquinolone) may be used with caution. Adverse effects may include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects. Use of fluoroquinolones has been restricted in certain indications.[43] 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][45]
Hot tub folliculitis is thought to be associated with under-chlorinated water. Spa water should thus be maintained with adequate concentration of chlorine and changed frequently.[39]
Fungal
For dermatophytic folliculitis, topical antifungal therapy (ketoconazole shampoo and cream) may be helpful in some cases. Systemic therapy with itraconazole or oral terbinafine is more likely to be effective. While some clinicians prefer continuous oral antifungal therapy for 2 to 3 weeks, others prefer monthly pulse therapy.
For Pityrosporum folliculitis, topical antifungal therapy (ketoconazole shampoo and cream) is used for mild cases. For recurrent cases of Pityrosporum folliculitis, consider systemic therapy with fluconazole or itraconazole.[28]
In Candida folliculitis, fluconazole or itraconazole therapy is generally effective.[46]
Herpes simplex
Oral aciclovir, valaciclovir, or famciclovir should be given to treat Herpes simplex folliculitis. A 5- to 10-day course of antiviral therapy is usually recommended.
Demodex
Topical permethrin cream or systemic ivermectin therapy is used to treat Demodex folliculitis.
Drug-induced folliculitis
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]
Eosinophilic
Consultation with a specialist is required for management of this condition. The first-line treatment for eosinophilic pustular folliculitis is oral indometacin. Several second-line treatments have been reported to control the disease with inconsistent results. They include UV-B phototherapy, minocycline, and dapsone. However, treatment success is based primarily on anecdotal reporting. For accompanying pruritus, topical antipruritics, topical corticosteroids, and oral antihistamines may be used.
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.
Eosinophilic pustular folliculitis in infancy is a self-limiting condition and tends to run a benign course. Associated pruritus can be treated with topical corticosteroids and oral antihistamines during flares.
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