What is the treatment for folliculitis?

Treatment of Folliculitis

For folliculitis, the recommended 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 extensive disease, systemic symptoms, or failed local treatment. 1

Diagnosis and Assessment

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

Treatment Algorithm

First-line Treatment (Mild to Moderate Cases):

1. Supportive Care:

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

2. Topical Therapy:

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

Second-line Treatment (Moderate to Severe Cases):

Oral antibiotics are indicated when there is:

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

Antibiotic Selection:

• For methicillin-susceptible S. aureus: dicloxacillin or cephalexin
• For MRSA: doxycycline, clindamycin, or trimethoprim-sulfamethoxazole (SMX-TMP)
• For Pseudomonas folliculitis: fluoroquinolones
• Duration: 7-10 days for acute cases, potentially longer for chronic cases 1

Special Considerations

For Recurrent Folliculitis:

1. Evaluate for underlying conditions such as diabetes or immunosuppression
2. Consider a 5-day decolonization regimen:
   • Intranasal mupirocin
   • Daily chlorhexidine washes
   • Daily decontamination of personal items 1

For Specific Types of Folliculitis:

• Folliculitis decalvans: Oral isotretinoin has shown high success rates (90% stable remission) compared to antibiotics 2
• Gram-negative folliculitis: Often occurs in acne patients after long-term tetracycline treatment; isotretinoin (0.5-1 mg/kg daily for 4-5 months) is the most effective treatment 3

Prevention Measures

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

When to Refer

Refer to a dermatologist if:

• No improvement after 2 weeks of treatment
• Extensive or severe disease
• Recurrent episodes
• Development of scarring
• Patient is immunocompromised 1

While several oral antibiotics have been studied for folliculitis treatment, comparative trials have not identified significant differences in efficacy or safety outcomes between different oral antibiotics 4. The choice should be guided by the suspected pathogen and local resistance patterns.