What is the treatment for folliculitis?

Treatment of Folliculitis

The first-line treatment for folliculitis is incision and drainage for fluctuant lesions, followed by topical antimicrobial therapy such as clindamycin solution, erythromycin solution, benzoyl peroxide, or chlorhexidine applied twice daily for at least 14 days. 1

Diagnosis and Initial Management

• Folliculitis is typically caused by:

  • Staphylococcus aureus (most common)
  • Streptococcus species
  • Polymicrobial infections

• Initial treatment approach:

  1. For fluctuant or abscess-like lesions: Perform incision and drainage

     • Make a small incision
     • Thoroughly evacuate pus
     • Cover with a dry dressing 1

  2. Apply topical antimicrobials twice daily for at least 14 days:

     • Clindamycin solution
     • Erythromycin solution
     • Benzoyl peroxide
     • Chlorhexidine 1

Systemic Antibiotic Therapy

Oral antibiotics are indicated for:

• Extensive surrounding cellulitis
• Fever or other systemic symptoms
• Multiple lesions
• Immunocompromised patients
• Failed local treatment 1

Antibiotic selection:

• For methicillin-susceptible S. aureus:

  • Dicloxacillin or cephalexin (first-line)

• For MRSA:

  • Doxycycline
  • Clindamycin
  • Trimethoprim-sulfamethoxazole (SMX-TMP)

• Duration: 7-10 days for acute cases, potentially longer for chronic cases 1

Special Types of Folliculitis

Folliculitis Decalvans

For this scarring alopecia variant:

• Oral isotretinoin is the most effective treatment with 90% of patients experiencing stable remission during and up to two years after treatment 2
• Antibiotics (clarithromycin, dapsone) show lower success rates (33-43%)
• Clindamycin/rifampicin combination has the highest relapse rate (80%) 2

EGFR Inhibitor-Induced Folliculitis

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

Pseudomonas Folliculitis (Hot Tub Folliculitis)

• Fluoroquinolones are effective when systemic therapy is required
• Proper maintenance of hot tubs is essential for prevention 1

Prevention and Hygiene Measures

• Regular cleansing with pH-neutral, non-irritating soaps
• Wear loose-fitting, cotton clothing
• Change clothing daily
• Avoid sharing personal items like razors or towels
• Consider trimming hair instead of shaving
• If shaving:
  • Use a clean, sharp razor
  • Shave in the direction of hair growth
  • Apply moisturizer after shaving 1

Follow-up and Management of Recurrence

• Reassess after 2 weeks of treatment

• For recurrent infections:

  • Evaluate for underlying conditions (diabetes, immunosuppression)
  • Consider a 5-day decolonization regimen:
    • Intranasal mupirocin
    • Daily chlorhexidine washes
    • Daily decontamination of personal items 1

• Escalate treatment or refer to dermatologist if:

  • No improvement or worsening occurs
  • Extensive or severe disease develops
  • Recurrent episodes despite appropriate treatment
  • Scarring develops
  • Patient is immunocompromised 1

Advanced Treatment Options

For chronic or refractory cases:

• Laser therapy can provide long-term resolution by targeting the hair follicle 1
• Photodynamic therapy may be effective for folliculitis decalvans 3
• Biologics (preferably adalimumab), JAK inhibitors, or cyclosporine can be considered for folliculitis decalvans 3

Common Pitfalls and Caveats

• Avoid alcohol-based products as they can worsen skin dryness
• Avoid prolonged use of topical steroids due to risk of skin atrophy
• Gram stain and culture of pus from abscesses are recommended to guide antibiotic therapy, especially in recurrent cases
• For folliculitis decalvans, remember that the goal is to control inflammation and prevent further hair loss; hair regrowth cannot be expected 3