What is the oral treatment for folliculitis?

Oral Treatment for Folliculitis

For typical bacterial folliculitis, oral tetracyclines (particularly doxycycline 100mg twice daily) are the first-line oral treatment due to their dual antimicrobial and anti-inflammatory properties. 1, 2

First-Line Oral Treatment Options

Tetracyclines

• Doxycycline: 100mg twice daily initially, then 100mg once daily after clinical improvement 2
  • Advantages: Less photosensitizing than other tetracyclines
  • Duration: 5-10 days for uncomplicated cases, longer for chronic cases
  • Contraindications: Pregnancy, children under 8 years, hypersensitivity to tetracyclines

Alternative First-Line Options

• Minocycline: 100mg twice daily
• Clindamycin: 150mg daily (particularly effective for recurrent furunculosis caused by susceptible S. aureus) 1

Treatment Algorithm Based on Folliculitis Type

1. Typical Bacterial Folliculitis

• First-line: Doxycycline 100mg twice daily for 5-10 days 1, 2
• Alternative: Cephalexin, dicloxacillin, or clindamycin if tetracyclines contraindicated

2. MRSA-Associated Folliculitis

• First-line: Clindamycin or combination of SMX-TMP with a β-lactam 1
• Note: MRSA is an unusual cause of typical folliculitis but should be considered with purulent drainage or history of MRSA infection

3. Gram-Negative Folliculitis

• First-line: Isotretinoin 0.5-1 mg/kg daily for 4-5 months 3
• This condition often occurs in patients on long-term tetracycline therapy for acne

4. Folliculitis Decalvans (Scarring Folliculitis)

• First-line for moderate/severe: Oral antibiotics (tetracyclines or combination of clindamycin and rifampicin) 4
• First-line for mild or refractory cases: Isotretinoin (shown to be most effective with 90% stable remission) 5, 4
• Alternative: Dapsone, fusidic acid 500mg three times daily 6

Special Considerations

For Recurrent Furunculosis

1. Eradication of nasal carriage:

   • Mupirocin ointment twice daily in anterior nares for first 5 days each month 1
   • OR Clindamycin 150mg daily for 3 months (reduces recurrences by ~80%) 1

2. Hygiene measures:

   • Bathing with antibacterial soaps (chlorhexidine)
   • Thorough laundering of clothing, towels, and bedding
   • Separate use of towels and washcloths 1

Pitfalls to Avoid

• Avoid greasy creams for skin care as they may facilitate folliculitis development due to occlusive properties 1
• Avoid manipulation of skin due to risk of infection 1
• Do not rely on β-lactams alone when MRSA is suspected (associated with penetrating trauma, purulent drainage) 1
• Do not continue tetracyclines indefinitely as this may lead to gram-negative folliculitis 3

Monitoring and Follow-up

• Patients should return for evaluation if no improvement after 3-4 days of treatment 1
• For severe or recurrent cases, bacterial culture may guide therapy 1
• For folliculitis decalvans, extended treatment beyond resolution of symptoms may be necessary to prevent recurrence 4

Remember that while oral antibiotics are effective for treating folliculitis, incision and drainage is the primary treatment for large furuncles and carbuncles, with systemic antibiotics reserved for cases with extensive surrounding cellulitis or fever 1.