What is the treatment for perforating folliculitis?

Treatment for Perforating Folliculitis

The treatment for perforating folliculitis should include topical antibiotics for mild cases, oral antibiotics for moderate to severe cases, and incision and drainage for large lesions, with consideration of decolonization regimens for recurrent cases. 1

First-Line Treatment Options

Mild Cases

• Topical therapy:
  • Topical antibiotics such as clindamycin or erythromycin for localized lesions 1
  • Topical antiseptics like benzoyl peroxide or chlorhexidine 1

Moderate to Severe Cases

• Oral antibiotics:
  • Tetracyclines or cephalosporins for 7-14 days 1
  • For MRSA concerns, select antibiotics based on local resistance patterns 1
  • Oral isotretinoin (0.5-1 mg/kg daily) has shown 90% success rate for long-term remission in folliculitis decalvans 1

For Large Lesions

• Incision and drainage is the recommended treatment for large furuncles or carbuncles 2, 1
• Cover the surgical site with a dry dressing after drainage 1
• Systemic antibiotics are usually unnecessary unless there is:
  • Fever or systemic inflammatory response syndrome (SIRS)
  • Extensive surrounding cellulitis
  • Severely impaired host defenses 2, 1

Management of Recurrent Cases

1. Search for underlying causes:

   • Local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material 2
   • Systemic disorders like diabetes mellitus or chronic renal failure 3, 4

2. Culture and targeted treatment:

   • Drain and culture recurrent abscesses early 2
   • Treat with a 5-10 day course of an antibiotic active against the isolated pathogen 2

3. Decolonization regimen:

   • 5-day regimen including:
     • Intranasal mupirocin twice daily
     • Daily chlorhexidine washes
     • Daily decontamination of personal items (towels, sheets, clothes) 2, 1

Prevention Measures

• Use gentle pH5 neutral soaps and shampoos with tepid water 2
• Pat skin dry rather than rubbing 2
• Wear fine cotton clothes instead of synthetic materials 2
• Avoid greasy creams as they may facilitate folliculitis due to occlusive properties 2, 1
• Complete avoidance of contaminated water sources for hot tub folliculitis 1

Special Considerations

• For EGFR inhibitor-induced folliculitis:

  • Moisturize skin with hypoallergenic creams
  • Avoid sun exposure
  • Use high SPF sunscreen
  • Consider oral tetracyclines for grade ≥2 rash 2, 1

• For perforating folliculitis associated with systemic disorders:

  • Address underlying conditions like diabetes mellitus or chronic renal failure 3, 4
  • Consider referral to appropriate specialists for management of associated conditions

When to Consider Referral

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

Treatment Pitfalls to Avoid

• Don't use topical steroids as they may cause perioral dermatitis and skin atrophy 2, 1
• Don't rely solely on antibiotics for large furuncles or carbuncles without drainage 2, 1
• Don't neglect to search for underlying causes in recurrent cases 2
• Don't forget to obtain bacterial cultures from pustules to confirm diagnosis and guide antibiotic selection in resistant or severe cases 1