What is the treatment for folliculitis?

Treatment of Folliculitis

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

Classification and Treatment Algorithm

Mild Folliculitis

• Topical therapy:
  • Clindamycin solution/gel
  • Erythromycin solution
  • Benzoyl peroxide
  • Chlorhexidine wash
  • Apply twice daily for 14 days 1

Moderate to Severe Folliculitis

• Oral antibiotics (7-14 days):
  • For MSSA: Dicloxacillin or cephalexin 1
  • For MRSA: Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole 1
  • Tetracyclines (doxycycline, minocycline) are particularly effective 1

Special Types of Folliculitis

• Malassezia folliculitis:

  • Topical antifungal: 2% ketoconazole cream until papules flatten (average 27 days) 2
  • Systemic: Oral itraconazole 100mg for more severe cases (average 14 days to improvement) 2

• Folliculitis decalvans (scarring alopecia):

  • Oral isotretinoin has shown 90% stable remission rate, superior to antibiotics 3
  • Fusidic acid 500mg three times daily has shown efficacy in some cases 4

Indications for Systemic Antibiotics

Systemic antibiotics are indicated when:

1. Extensive surrounding cellulitis is present
2. Patient has fever or other systemic symptoms
3. Multiple lesions are present
4. Patient is immunocompromised
5. Local treatment has failed 1

Treatment for Recurrent Folliculitis

For recurrent cases, consider decolonization protocols:

• Mupirocin ointment to anterior nares twice daily for first 5 days each month 1
• Daily chlorhexidine washes
• Daily decontamination of personal items 1
• Evaluate for underlying conditions like diabetes or immunosuppression

Prevention Measures

• Proper hygiene with pH-neutral, non-irritating soaps
• Wear loose-fitting cotton clothing
• Change clothing daily
• Avoid sharing personal items like razors or towels
• Proper shaving techniques (avoid shaving too close to skin, use clean razors)
• Avoid greasy creams and occlusive products 1

Treatment Monitoring

• Reassess after 2 weeks of treatment
• If no improvement or worsening occurs, escalate to the next level of treatment or refer to a dermatologist 1

Pitfalls and Caveats

1. Misdiagnosis: Ensure proper diagnosis before treatment, as fungal folliculitis requires antifungal therapy rather than antibiotics.
2. Antibiotic resistance: Avoid prolonged antibiotic use to prevent resistance development.
3. Underlying conditions: Recurrent folliculitis may indicate underlying conditions like diabetes or immunosuppression that need addressing.
4. Treatment failure: Consider bacterial culture and sensitivity testing if standard treatments fail.
5. Scarring potential: Aggressive or deep folliculitis may lead to scarring if not treated promptly.

While comparative trials have not identified important differences in efficacy or safety outcomes between different oral antibiotics for treating bacterial folliculitis 5, a structured approach based on severity and type of folliculitis provides the best outcomes for patients.