What is the treatment for folliculitis?

Treatment of Folliculitis

For most cases of folliculitis, treatment should include topical antibiotics as first-line therapy, with oral antibiotics reserved for more severe or widespread cases. 1

Types and Diagnosis

Folliculitis is an inflammation of the hair follicle that can be classified into several types:

• Simple folliculitis: Superficial inflammation limited to the epidermis
• Furuncles (boils): Deeper infection extending through the dermis into subcutaneous tissue
• Carbuncles: Coalescent inflammatory mass with pus draining from multiple follicular orifices

The most common causative organism is Staphylococcus aureus, though other bacteria, fungi, or viruses may be involved.

Treatment Algorithm

Mild Folliculitis (Limited, Superficial)

1. Topical antibiotics:

   • Mupirocin 2% ointment applied three times daily for 5-10 days 2
   • Continue until clinical response is seen (typically within 3-5 days)

2. Hygiene measures:

   • Use gentle pH5 neutral soaps and shampoos with tepid water 1
   • Pat skin dry rather than rubbing 1
   • Wear fine cotton clothes instead of synthetic materials 1
   • Avoid greasy creams which may facilitate folliculitis development 1

Moderate to Severe Folliculitis (Extensive or Deep)

1. Oral antibiotics:

   • Tetracyclines (doxycycline or minocycline) for their antimicrobial and anti-inflammatory effects 1
   • Alternative options include cephalosporins or clindamycin 1
   • Treatment duration: 5-10 days for acute cases 1

2. For furuncles and carbuncles:

   • Incision and drainage is the recommended treatment for large furuncles and all carbuncles 1
   • Systemic antibiotics are usually unnecessary unless fever or other evidence of systemic infection is present 1

For Recurrent Folliculitis

1. Culture recurrent lesions to identify the causative organism 1
2. Treat with a 5-10 day course of an antibiotic active against the isolated pathogen 1
3. Consider decolonization regimen:
   • Intranasal mupirocin twice daily
   • Daily chlorhexidine washes
   • Daily decontamination of personal items (towels, sheets, clothes) 1

Special Considerations

For MRSA Infections

• Use antibiotics active against MRSA (trimethoprim-sulfamethoxazole, doxycycline, or clindamycin) 1

For Folliculitis Decalvans (Scalp)

• Oral isotretinoin has shown the highest success rate (90% stable remission) compared to antibiotics 3
• Oral fusidic acid (500mg three times daily) has also shown effectiveness 4

For Eosinophilic Pustular Folliculitis

• Topical tacrolimus 0.1% has shown rapid improvement 5

Common Pitfalls to Avoid

1. Overuse of topical steroids: May cause skin atrophy, perioral dermatitis, and can exacerbate folliculitis 1

2. Inappropriate use of topical acne medications: These may irritate and worsen folliculitis due to their drying effects 1

3. Inadequate drainage of furuncles/carbuncles: Incision and drainage is essential for larger lesions 1

4. Failure to identify underlying causes of recurrent folliculitis such as:

   • Pilonidal cyst
   • Hidradenitis suppurativa
   • Foreign material 1

5. Neglecting hygiene measures: Proper skin care is essential for prevention and treatment 1

By following this treatment approach based on severity and type of folliculitis, most cases will resolve with minimal complications. For recurrent or treatment-resistant cases, further evaluation for underlying conditions or resistant organisms should be pursued.