What is the treatment for hair folliculitis?

Treatment of Hair Folliculitis

The treatment of hair folliculitis primarily involves incision and drainage for large furuncles and all carbuncles, with systemic antibiotics generally reserved for cases with systemic symptoms or extensive surrounding cellulitis. 1

Types and Clinical Presentation

Hair folliculitis presents as inflammation of the hair follicle, with the following variants:

• Superficial folliculitis: Inflammation limited to the epidermis
• Furuncles (boils): Deeper infection extending through dermis into subcutaneous tissue
• Carbuncles: Coalescent inflammatory mass involving several adjacent follicles, often on the back of the neck and common in diabetic patients

Treatment Algorithm

1. Mild Superficial Folliculitis

• First-line:
  • Gentle cleansing with pH-neutral bath/shower formulations
  • Topical antibiotics (alcohol-free formulations) for 14 days
  • Avoid greasy moisturizers that may occlude follicles 2

2. Furuncles (Boils)

• Small furuncles:
  • Application of moist heat to promote drainage 1
• Larger furuncles:
  • Incision and drainage (strong recommendation, high-quality evidence) 1
  • Systemic antibiotics generally unnecessary unless extensive surrounding cellulitis or fever present 1

3. Carbuncles

• All carbuncles:
  • Incision and drainage (strong recommendation, high-quality evidence) 1
  • Consider systemic antibiotics if SIRS present (temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or WBC >12,000 or <400 cells/μL) 1

4. Special Considerations

Recurrent Folliculitis

• Search for local causes (e.g., pilonidal cyst, hidradenitis suppurativa, foreign material) 1
• Early drainage and culture of recurrent abscesses 1
• 5-10 day course of antibiotics active against cultured pathogen 1
• Consider 5-day decolonization regimen:
  • Intranasal mupirocin twice daily
  • Daily chlorhexidine washes
  • Daily decontamination of personal items (towels, sheets, clothes) 1

Specific Types of Folliculitis

Pityrosporum Folliculitis:

• Often misdiagnosed as acne vulgaris
• Characterized by pruritic papules/pustules on upper body and face
• Treatment: Oral antifungals (92% success rate) or topical antifungals (81.6% success rate) 3

Folliculitis Decalvans:

• Oral antibiotics (tetracyclines or clindamycin with rifampicin)
• Fusidic acid 500mg three times daily has shown good results 4

Diagnostic Considerations

• Gram stain and culture of pus from carbuncles and abscesses are recommended (strong recommendation, moderate evidence) 1
• Gram stain and culture of pus from inflamed epidermoid cysts are not recommended 1

Common Pitfalls to Avoid

1. Overuse of systemic antibiotics: Reserve for cases with systemic symptoms, extensive cellulitis, or immunocompromised patients
2. Inadequate drainage: Thorough evacuation of pus and probing to break up loculations is essential for abscesses
3. Misdiagnosis: Pityrosporum folliculitis is often mistaken for acne vulgaris, leading to ineffective treatment 3
4. Neglecting recurrence prevention: For recurrent cases, decolonization regimens are important

Follow-up

• Most cases should show improvement within 48-72 hours of appropriate treatment
• If no improvement after this time, reassess diagnosis and consider alternative treatments 2
• For recurrent cases, evaluate for neutrophil disorders if abscesses began in early childhood 1

By following this evidence-based approach, most cases of hair folliculitis can be effectively managed, preventing progression to more severe infection and reducing the risk of recurrence.