What is the treatment for folliculitis that occurs around the menstrual cycle?

Treatment for Folliculitis Associated with Menstrual Cycle

For folliculitis that occurs around the menstrual cycle, hormonal therapy with spironolactone (100-150 mg daily) is recommended as first-line treatment due to its high efficacy in managing hormonally-influenced folliculitis. 1

Understanding Menstrual-Associated Folliculitis

Folliculitis that flares around menstrual cycles suggests hormonal influence on the condition. This pattern indicates that androgens may be playing a significant role in the pathogenesis, similar to what is observed in hidradenitis suppurativa.

Treatment Algorithm

First-Line Treatment Options:

1. Hormonal Therapy:

   • Spironolactone: 100-150 mg daily
     • Has shown 85% improvement rate in women with hormonally-influenced follicular disorders 1
     • Complete remission achieved in 55% of patients
   • Combined Oral Contraceptives: Containing ethinyl estradiol with anti-androgenic progestins
     • Avoid progestogen-only regimens as they may worsen symptoms 1

2. Topical Treatments (to be used concurrently):

   • Topical clindamycin 1% solution/gel twice daily for 2-3 weeks 2
   • Gentle skin care:
     • pH-neutral soaps and shampoos
     • Tepid water
     • Pat skin dry rather than rubbing 2

Second-Line Treatment Options:

1. Systemic Antibiotics:

   • Tetracycline: 500 mg twice daily for up to 4 months for moderate to severe cases 2
   • Dicloxacillin, cephalexin, clindamycin, or erythromycin for bacterial folliculitis 2

2. For Recalcitrant Cases:

   • Metformin: 500 mg 2-3 times daily
     • Particularly effective in women with polycystic ovarian syndrome features 1
   • Finasteride: 1.25-5 mg daily as adjunctive or monotherapy 1

Special Considerations

For Severe or Recurrent Cases:

• Consider combination of clindamycin 300 mg twice daily with rifampicin 600 mg once daily for 10 weeks 2
• Treatment duration may need to be extended to 2-3 weeks for more severe cases 2

Prevention Strategies:

• Avoid greasy creams and wear fine cotton clothes instead of synthetic materials 2
• Consider chlorhexidine washes or antibacterial soaps to prevent recurrence 2
• Thoroughly launder clothing, towels, and bedding to prevent spread of infection 2

When to Refer to a Specialist

• If no improvement after 2 weeks of treatment
• Development of scarring
• Extensive or severe disease
• Recurrent episodes despite appropriate treatment 2

Important Caveats

• Progestogen-only contraceptives may worsen folliculitis in some patients and should be used with caution 1
• Culture and sensitivity testing may be necessary if standard treatments fail to identify specific pathogens 3
• Consider the possibility of fungal folliculitis if bacterial treatments fail, which would require antifungal therapy 4
• Treatment should be continued beyond resolution of symptoms to prevent recurrences, especially in hormonally-influenced cases 5