What is the treatment for folliculitis?

Treatment for Folliculitis

The treatment of folliculitis should include topical antibiotics for mild cases, oral antibiotics for moderate to severe cases, and isotretinoin for refractory cases or gram-negative folliculitis. 1, 2

Types and Diagnosis

Folliculitis is an inflammation of the hair follicle that can be classified as:

• Superficial (limited to the upper portion of the hair follicle)
• Deep (affecting the entire hair follicle)
• Infectious (bacterial, fungal, viral)
• Non-infectious (chemical, physical irritation)

Key diagnostic features include:

• Erythematous papules or pustules centered around hair follicles
• Presence of pain, itching, or burning
• Distribution in hair-bearing areas (scalp, beard, chest, back, extremities)

Treatment Algorithm

First-Line Treatment for Mild Folliculitis:

1. Personal Hygiene Measures:

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

2. Topical Therapy:

   • Topical antibiotics (clindamycin, erythromycin) for localized lesions
   • Topical antiseptics such as benzoyl peroxide or chlorhexidine 2
   • Avoid topical steroids as they may cause perioral dermatitis and skin atrophy 1

Second-Line Treatment for Moderate to Severe Folliculitis:

1. Oral Antibiotics:

   • Tetracyclines (doxycycline, minocycline) for their anti-inflammatory effects
   • Cephalosporins (cefadroxil, cefdinir) or flucloxacillin for Staphylococcal infections 2
   • Duration: 7-14 days for acute cases; may need longer for chronic cases

2. For Secondary Infection:

   • Obtain bacterial swabs to identify causative organisms
   • Treat according to culture and sensitivity results
   • Common pathogens include Staphylococcus aureus (most frequent), streptococci 1
   • For MRSA: Consider vancomycin or other antibiotics based on sensitivity

Treatment for Refractory or Special Cases:

1. Isotretinoin:

   • Most effective for gram-negative folliculitis (0.5-1 mg/kg daily for 4-5 months) 3
   • Highly effective for folliculitis decalvans with 90% stable remission rate 4
   • Consider as first-line for mild active disease with perifollicular erythema and hyperkeratosis 5

2. For Folliculitis Decalvans (scarring alopecia):

   • Oral antibiotics for moderate to severe inflammation
   • Short course of oral glucocorticosteroids for highly active disease
   • Consider biologics (adalimumab), JAK inhibitors, dapsone, or cyclosporine for resistant cases 5

3. For EGFR Inhibitor-Induced Folliculitis:

   • Moisturize skin with hypoallergenic creams
   • Avoid sun exposure and use high SPF sunscreen
   • For grade ≥2 rash: oral tetracyclines (doxycycline, minocycline) 1

Special Considerations

1. Pitfalls to Avoid:

   • Avoid greasy creams for basic care as they might facilitate folliculitis development
   • Avoid manipulation of skin due to risk of infection
   • Do not use topical acne medications without dermatologist supervision as they may irritate and worsen the condition 1

2. When to Consider Alternative Diagnoses:

   • Persistent folliculitis despite appropriate therapy
   • Unusual distribution or appearance
   • Associated systemic symptoms
   • Consider fungal (pityrosporum folliculitis) or viral etiologies

3. When to Refer to Specialist:

   • Extensive or severe disease
   • Recurrent episodes despite appropriate treatment
   • Development of scarring (folliculitis decalvans)
   • Immunocompromised patients

The evidence suggests that while antibiotics are commonly used for folliculitis, isotretinoin may be more effective for certain types, particularly gram-negative folliculitis and folliculitis decalvans 4, 3. For mild cases, topical treatments and hygiene measures are often sufficient, while moderate to severe cases typically require systemic therapy.