What is the treatment for folliculitis?

Treatment of Folliculitis

The treatment of folliculitis should begin with topical antiseptics such as benzoyl peroxide or chlorhexidine wash, with topical antibiotics like clindamycin or erythromycin for localized lesions, and oral antibiotics for moderate to severe cases. 1

Classification and Initial Approach

Folliculitis can be classified as:

• Superficial or deep
• Infectious or non-infectious

The treatment approach depends on the severity, extent, and type of folliculitis:

Mild Localized Folliculitis

• First-line treatment:
  • Topical antiseptics: benzoyl peroxide or chlorhexidine wash
  • Topical antibiotics: clindamycin or erythromycin for localized lesions 1

Moderate to Severe Folliculitis

• Systemic antibiotics:
  • Tetracyclines or cephalosporins for 7-14 days for acute cases 1
  • Consider obtaining bacterial cultures to guide antibiotic selection for resistant cases 1

Specific Types of Folliculitis

Bacterial Folliculitis (Staphylococcal)

1. Topical treatments:

   • Antiseptic washes (chlorhexidine, benzoyl peroxide)
   • Topical antibiotics (mupirocin, clindamycin) 1

2. Systemic treatment for extensive or severe cases:

   • Oral antibiotics (cephalosporins, tetracyclines)
   • Duration: 7-14 days for acute cases 1

Gram-Negative Folliculitis

• Often develops in patients on long-term tetracycline therapy for acne
• Treatment of choice: Oral isotretinoin (0.5-1 mg/kg daily for 4-5 months) with 90% success rate for long-term remission 2, 3

Folliculitis Decalvans (Scalp)

• Most effective treatment: Oral isotretinoin (0.5-1 mg/kg daily) 1, 2
• Alternative treatments:
  • Combination of clindamycin and rifampicin (high relapse rate of 80%)
  • Clarithromycin (33% long-term remission)
  • Dapsone (43% long-term remission) 2

Pseudomonas Folliculitis ("Hot Tub Folliculitis")

• Often self-limiting within 7-10 days
• Treatment: Fluoroquinolones when systemic therapy is required 1

Management of Boils and Furuncles

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

Prevention of Recurrent Folliculitis

• Decolonization regimen:

  • Intranasal mupirocin
  • Daily chlorhexidine washes
  • Daily decontamination of personal items 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 occlusive creams 1

When to Refer to a Specialist

Referral to a dermatologist is recommended for:

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

Important Considerations

• Avoid misdiagnosis: Consider fungal infections (tinea capitis) that may mimic bacterial folliculitis, especially on the scalp 1
• Avoid topical steroids: They may cause perioral dermatitis and skin atrophy 1
• Culture and sensitivity: Important for recurrent or resistant cases to guide antibiotic selection 1, 4

The Cochrane review on bacterial folliculitis treatments noted that comparative trials have not identified important differences in efficacy or safety outcomes between different oral antibiotics 4. However, the American Academy of Dermatology guidelines and clinical practice suggest that targeted therapy based on culture results and severity is most effective for managing folliculitis.