What is the treatment for folliculitis?

Treatment of Folliculitis

For most cases of folliculitis, treatment should include topical antibiotics such as clindamycin or erythromycin for localized lesions, while moderate to severe cases require oral antibiotics like tetracyclines or cephalosporins for 7-14 days. 1

Classification and Diagnosis

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

• Superficial or deep
• Infectious or non-infectious

Key diagnostic features include:

• Erythematous papules or pustules centered around hair follicles
• Pain, itching, or burning sensations
• Distribution in hair-bearing areas 1

Treatment Algorithm

First-Line Treatment Options

1. Mild, Localized Folliculitis:

   • Topical antibiotics (clindamycin or erythromycin) 1
   • Topical antiseptics (benzoyl peroxide or chlorhexidine wash) 1
   • Personal hygiene measures:
     • Use gentle pH5 neutral soaps and shampoos with tepid water
     • Pat skin dry rather than rub
     • Wear fine cotton clothes instead of synthetic materials
     • Avoid greasy, occlusive creams 1

2. Moderate to Severe Folliculitis:

   • Oral antibiotics for 7-14 days:
     • Tetracyclines
     • Cephalosporins (e.g., cephalexin) 1, 2
   • Consider bacterial cultures to guide antibiotic selection for resistant cases 1

3. Follicular Abscesses/Furuncles:

   • Incision and drainage for large furuncles
   • Systemic antibiotics if SIRS (systemic inflammatory response syndrome) is present 1

Special Types of Folliculitis

1. Folliculitis Decalvans:

   • Oral antibiotics for moderate/severe inflammation 3
   • Oral isotretinoin (0.5-1 mg/kg daily) for mild active disease or refractory cases - shows highest success rate (90%) for long-term remission 1, 3
   • Short course of oral glucocorticosteroids for highly active disease 3
   • Fusidic acid (500 mg three times daily) has shown efficacy in some cases 4

2. Recurrent Folliculitis:

   • 5-day decolonization regimen:
     • Intranasal mupirocin
     • Daily chlorhexidine washes
     • Daily decontamination of personal items 1
   • Consider combination therapy with topical and oral antibiotics 1

3. Pseudomonas Aeruginosa Folliculitis:

   • Fluoroquinolones when systemic therapy is required 1

4. Gram-Negative Folliculitis:

   • Isotretinoin (0.5-1 mg/kg daily for 4-5 months) 1

Treatment-Resistant Cases

For refractory cases, consider:

• Photodynamic therapy
• Biologics (preferably adalimumab)
• JAK inhibitors
• Oral dapsone
• Hydroxychloroquine
• Cyclosporine 3

When to Refer to a Specialist

Referral is recommended for:

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

Common Pitfalls and Caveats

1. Misdiagnosis: Fungal infections of the scalp (tinea capitis) can be misdiagnosed as bacterial folliculitis. Consider laboratory investigations to confirm diagnosis 1

2. Inappropriate Treatment Duration: Many cases of folliculitis, especially folliculitis decalvans, may require extended treatment beyond resolution of symptoms to prevent recurrence 3, 2

3. Topical Steroid Use: Avoid topical steroids on the face as they may cause perioral dermatitis and skin atrophy 1

4. Inadequate Culture: For recurrent or resistant cases, obtaining bacterial cultures before initiating antibiotics is crucial to guide appropriate therapy 1

5. Overlooking Underlying Conditions: Some cases of folliculitis may be associated with systemic diseases or immunodeficiency that require additional management 4