Treatment for Systemic Folliculitis
For systemic folliculitis, oral tetracyclines (doxycycline or minocycline) are the first-line treatment, with isotretinoin (0.5-1 mg/kg daily for 4-5 months) recommended for gram-negative folliculitis or cases resistant to standard therapy. 1, 2
Diagnostic Approach
When evaluating systemic folliculitis, consider:
- Distribution of lesions (localized vs. widespread)
- Duration (acute vs. chronic)
- Associated symptoms (fever, pain, pruritus)
- Previous antibiotic exposure (especially long-term tetracyclines)
- Immunocompromised status
Obtain bacterial cultures from pustules to identify causative organisms, particularly if:
- There is poor response to initial therapy
- Recurrent episodes occur
- Patient has risk factors for resistant organisms
- Unusual presentation or severe systemic symptoms are present
Treatment Algorithm
First-Line Treatment:
- Oral tetracyclines: Doxycycline 100mg twice daily or minocycline 100mg twice daily for 2-4 weeks 1
- Tetracyclines work through both antimicrobial and anti-inflammatory effects
- Doxycycline has more photosensitizing effects than minocycline
- Minocycline may cause vestibular dizziness, hyperpigmentation, or rarely lupus-like syndrome
For Severe or Resistant Cases:
- Incision and drainage for large furuncles and all carbuncles 1
- Systemic antibiotics based on culture and sensitivity results
- Consider combination therapy with rifampin and clindamycin for resistant cases 3
For Gram-Negative Folliculitis:
- Isotretinoin (0.5-1 mg/kg daily for 4-5 months) is the treatment of choice 2
- Consider this diagnosis in patients who have been on long-term tetracycline therapy (3-6 months) without improvement
For Recurrent Folliculitis:
- Decolonization regimen: Intranasal mupirocin twice daily, daily chlorhexidine washes, and daily decontamination of personal items for 5 days 1
- Maintenance therapy: For nasal carriers of S. aureus, consider mupirocin ointment twice daily in the anterior nares for the first 5 days each month 1
- For persistent recurrences: Consider clindamycin 150mg daily for 3 months 1
Adjunctive Measures
Personal hygiene:
- Use gentle pH5 neutral soaps and shampoos with tepid water
- Pat skin dry rather than rubbing
- Wear fine cotton clothes instead of synthetic materials
- Careful shaving techniques 1
Avoid:
- Greasy creams (may facilitate folliculitis development)
- Manipulation of skin (increases infection risk)
- Hot blow-drying of hair
- Tight-fitting clothing or shoes 1
Special Considerations
- Immunocompromised patients may require longer treatment courses and closer monitoring
- Secondary infections may require broader antimicrobial coverage based on culture results
- Folliculitis decalvans (a rare neutrophilic cicatricial alopecia) may respond to fusidic acid 500mg three times daily 4
Monitoring and Follow-up
- Evaluate response after 7-10 days of treatment
- If no improvement, consider:
- Culture and sensitivity testing
- Alternative diagnosis
- Resistant organisms
- Underlying conditions affecting immune response
Pitfalls and Caveats
- Failure to identify and treat underlying causes may lead to recurrence
- Long-term antibiotic use can lead to gram-negative folliculitis, particularly in acne patients
- Topical steroids should be avoided as they may cause perioral dermatitis and skin atrophy 1
- Systemic antibiotics should be used judiciously to prevent antimicrobial resistance
By following this treatment approach, most cases of systemic folliculitis can be effectively managed, reducing morbidity and preventing complications such as scarring and recurrence.