What is the treatment for folliculitis?

Treatment of Folliculitis

For folliculitis, first-line treatment includes topical antimicrobials such as clindamycin solution, erythromycin solution, benzoyl peroxide, or chlorhexidine applied twice daily for at least 14 days, with oral antibiotics reserved for more extensive or severe cases. 1

Diagnosis and Assessment

• Folliculitis presents as pruritic papules, papulopustules, and occasionally nodules
• Reassess patients after 7-10 days (typical resolution time for most cases)
• Consider culture of pustules if:
  • Symptoms persist beyond 10 days
  • Infection appears to be worsening
  • Patient is immunocompromised 1

Treatment Algorithm

Mild to Moderate Folliculitis

1. Supportive Care:

   • Gentle cleansing with pH-neutral, non-irritating soaps
   • Warm compresses to promote drainage
   • Avoid alcohol-based products that worsen skin dryness 1

2. Topical Treatment:

   • Antiseptics: chlorhexidine (0.1%) wash or benzoyl peroxide preparations
   • Antimicrobials: clindamycin solution, erythromycin solution
   • Apply twice daily for at least 14 days 1

Moderate to Severe Folliculitis

1. Oral Antibiotics (indicated for):

   • Extensive surrounding cellulitis
   • Systemic symptoms (fever, malaise)
   • Multiple lesions
   • Immunocompromised patients
   • Failed local treatment 1

2. Antibiotic Options:

   • For MSSA: Dicloxacillin or cephalexin
   • For MRSA: Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole
   • Treatment duration: 7-10 days for acute cases 1

Special Types of Folliculitis

1. Malassezia Folliculitis:

   • Topical antifungals: 2% ketoconazole cream until papules flatten (average 27 days)
   • Oral antifungals: Itraconazole 100mg daily for faster resolution (average 14 days) 2

2. Folliculitis Decalvans (scarring alopecia):

   • Oral isotretinoin has shown 90% stable remission rate, superior to antibiotics 3
   • Alternative: Fusidic acid 500mg three times daily has shown good results 4

When to Refer to a Dermatologist

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

Prevention Strategies

• Maintain proper hygiene with pH-neutral soaps
• Wear loose-fitting, cotton clothing
• Change clothing daily
• Avoid sharing personal items like razors or towels
• For hot tub folliculitis: proper maintenance of hot tubs with adequate chlorine/bromine levels 1

Treatment Pitfalls and Caveats

1. Misdiagnosis: Bacterial folliculitis is often confused with fungal folliculitis, which requires antifungal rather than antibiotic treatment 5

2. Antibiotic Resistance: Overuse of antibiotics can lead to resistance; use topical treatments for mild cases when possible 1

3. Recurrence: For recurrent infections, evaluate for underlying conditions such as diabetes or immunosuppression, and consider decolonization regimens 1

4. Treatment Failure: If no improvement after 2 weeks, escalate to the next level of treatment or refer to a dermatologist 1

5. Chronic Cases: May require longer treatment courses or alternative therapies such as laser treatment for persistent folliculitis 1