What is the treatment for folliculitis?

Treatment of Folliculitis

For folliculitis, the recommended treatment includes topical antimicrobials (clindamycin, erythromycin, benzoyl peroxide, or chlorhexidine) applied twice daily for at least 14 days, with oral antibiotics reserved for extensive disease, systemic symptoms, or failed topical treatment. 1

Treatment Algorithm

First-Line Treatment

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

Second-Line Treatment (When to Use Oral Antibiotics)

Oral antibiotics are indicated for:

1. Extensive surrounding cellulitis
2. Systemic symptoms (fever, malaise)
3. Multiple lesions
4. Immunocompromised patients
5. Failed local treatment 1

Antibiotic Selection

• For methicillin-susceptible S. aureus:
  • Dicloxacillin or cephalexin 1
• For MRSA:
  • Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole (SMX-TMP) 1
• For Pseudomonas aeruginosa (hot tub folliculitis):
  • Fluoroquinolones 1
• Duration: 7-10 days for acute cases; potentially longer for chronic cases 1

Special Types of Folliculitis

Folliculitis Decalvans

While the American Academy of Dermatology guidelines recommend antibiotics as first-line therapy, more recent research suggests that oral isotretinoin may be more effective for this specific type of folliculitis, with 90% of patients experiencing stable remission during and up to two years after treatment 2. This contrasts with antibiotics, which showed higher relapse rates.

Monitoring and Follow-up

• Reassess after 7-10 days (typical resolution time for hot tub folliculitis)
• Consider culture of pustules if:
  • Symptoms persist beyond 10 days
  • Infection appears to be worsening
  • Patient is immunocompromised 1
• If no improvement after 2 weeks of treatment, escalate to the next level of treatment or refer to a dermatologist 1

Prevention Strategies

• Maintain proper hygiene:
  • Regular cleansing with pH-neutral soaps
  • Wear loose-fitting, cotton clothing
  • Change clothing daily
  • Avoid sharing personal items like razors or towels 1
• For hot tub-related folliculitis:
  • Follow manufacturer's recommendations for cleaning and disinfection
  • Maintain adequate chlorine or bromine levels
  • Regularly drain and clean the tub and filtering system 1

When to Refer to a Dermatologist

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

Common Pitfalls to Avoid

1. Failure to identify the causative organism: Consider culture for persistent or severe cases
2. Overuse of antibiotics: Reserve systemic antibiotics for cases that meet specific criteria
3. Neglecting underlying conditions: For recurrent infections, evaluate for diabetes or immunosuppression
4. Inadequate treatment duration: Ensure topical treatments are continued for at least 14 days
5. Missing MRSA: Consider MRSA coverage if standard treatments fail or in high-risk settings

The evidence for treatment efficacy varies, with limited high-quality randomized controlled trials comparing different interventions for folliculitis 3. However, the American Academy of Dermatology recommendations provide a practical approach based on clinical experience and available evidence.