What are the treatment options for folliculitis?

Treatment Options for Folliculitis

For folliculitis treatment, topical antimicrobials like clindamycin 1% solution/gel applied twice daily for 2-3 weeks are recommended as first-line therapy for mild cases, while oral antibiotics such as tetracycline 500mg twice daily or doxycycline are indicated for moderate to severe cases. 1

Types and Diagnosis

Folliculitis is an inflammatory condition of hair follicles that can be caused by:

• Bacterial infections (most commonly Staphylococcus aureus)
• Fungal infections (including Malassezia species)
• Gram-negative bacteria (including Pseudomonas from hot tubs)
• Non-infectious causes

Proper diagnosis is essential for effective treatment:

• Culture of pustules to identify specific pathogens
• Examination for characteristic features (superficial pustules, papules)
• Assessment of distribution pattern (face, chest, back, scalp)

Treatment Algorithm

1. Mild Superficial Folliculitis

• First-line: Topical antimicrobials applied twice daily for at least 14 days 1
  • Clindamycin 1% solution/gel
  • Erythromycin solution
  • Benzoyl peroxide
  • Chlorhexidine

2. Moderate to Severe Bacterial Folliculitis

• First-line: Oral antibiotics for 7-14 days (longer for chronic cases) 1
  • Tetracycline 500mg twice daily
  • Doxycycline (alternative to tetracycline)
  • For MRSA: Trimethoprim-sulfamethoxazole, doxycycline, or clindamycin

3. Extensive or Refractory Bacterial Folliculitis

• Clindamycin 300mg twice daily with rifampicin 600mg once daily for 10 weeks 1

4. Pityrosporum (Malassezia) Folliculitis

• Oral antifungals (92% success rate) 2
• Topical antifungals (81.6% success rate) 2

5. Folliculitis Decalvans (Scarring Alopecia)

• First-line for mild active disease: Oral isotretinoin (90% stable remission) 3, 4
• For moderate/severe inflammation: Oral antibiotics 4
• For highly active disease: Short course of oral glucocorticosteroids 4
• Refractory cases: Consider photodynamic therapy, biologics (adalimumab), JAK inhibitors, dapsone, hydroxychloroquine, or cyclosporine 4

Prevention Strategies

• Gentle skin care with pH-neutral soaps and shampoos 1
• Avoid greasy creams and wear fine cotton clothing 1
• Proper shaving techniques:
  • Avoid shaving too close to skin
  • Use sharp, clean razors
  • Wear loose-fitting cotton clothing 1
• Regular cleansing with non-irritating soaps 1
• Avoid sharing personal items like razors or towels 1

When to Refer to a Dermatologist

Refer patients with:

• Extensive or severe disease
• Recurrent episodes
• Development of scarring
• Immunocompromised status
• No improvement after 2-4 weeks of appropriate treatment 1

Important Clinical Considerations

• Pityrosporum folliculitis is often misdiagnosed as acne vulgaris and can be distinguished by the presence of pruritus (71.7% of cases) 2
• Folliculitis decalvans is a form of scarring alopecia where the goal is to control inflammation and prevent further hair loss; hair regrowth cannot be expected 4
• Laser therapy may provide long-term resolution for chronic or severe pseudofolliculitis barbae by targeting the hair follicle 1
• Cytology is a simple, rapid, and inexpensive diagnostic method that can help identify various bacterial, fungal, viral, and parasitic pathogens 5