What is the treatment for folliculitis?

Treatment for Folliculitis

For folliculitis, treatment should begin with personal hygiene measures and topical therapy, progressing to oral antibiotics for moderate to severe cases, with consideration of isotretinoin for refractory cases. 1

First-Line Treatment Approach

Personal Hygiene and Topical Therapy

• 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
• Apply topical antibiotics such as clindamycin or erythromycin for localized lesions
• Consider topical antiseptics like benzoyl peroxide or chlorhexidine 1

For Pseudomonal Folliculitis

• For Pseudomonas aeruginosa folliculitis (often associated with hot tubs or inadequately chlorinated swimming pools), fluoroquinolones offer an effective oral treatment option when systemic therapy is required 2

Second-Line Treatment: Oral Antibiotics

For moderate to severe cases that don't respond to topical therapy:

• Tetracyclines or cephalosporins for 7-14 days in acute cases
• Longer duration may be needed for chronic cases 1
• For secondary infection, obtain bacterial swabs to identify causative organisms
• Common pathogens include Staphylococcus aureus and streptococci 1

For Specific Types of Folliculitis

Pityrosporum (Malassezia) Folliculitis

• Selenium sulfide shampoo applied to affected areas
• 50% propylene glycol in water
• Topical antifungal creams (e.g., econazole) 3
• Oral antifungals may be considered for extensive cases

Folliculitis Decalvans

• Oral isotretinoin (0.5-1 mg/kg daily) has shown the highest success rate (90% stable remission) compared to antibiotics 4
• Antibiotics like clindamycin plus rifampicin have shown lower success rates with 80% relapse shortly after treatment 4

Refractory Cases

For cases that don't respond to standard therapy:

• Consider oral isotretinoin at 0.5-1 mg/kg daily for 4-5 months 1
• For gram-negative folliculitis specifically, isotretinoin is particularly effective 1
• For EGFR inhibitor-induced folliculitis, consider oral tetracyclines for grade ≥2 rash 1

Treatment Pitfalls to Avoid

• Don't use topical steroids - they may cause perioral dermatitis and skin atrophy 1
• Avoid manipulation of skin - increases risk of spreading infection 1
• Don't use topical acne medications without dermatologist supervision - may irritate and worsen the condition 1
• Don't discontinue treatment prematurely - may lead to recurrence, especially with Pityrosporum folliculitis 3

When to Refer to a Specialist

• Extensive or severe disease
• Recurrent episodes despite appropriate treatment
• Development of scarring
• Immunocompromised patients 1

Folliculitis treatment should be tailored to the severity and type of infection, with careful attention to identifying the causative organism when possible. Early intervention with appropriate therapy can prevent progression to more serious conditions and reduce the risk of scarring.