What is the treatment for folliculitis?

Treatment of Folliculitis

The first-line treatment for folliculitis is topical clindamycin 1% solution/gel twice daily for 2-3 weeks for mild cases, while oral antibiotics such as dicloxacillin, cephalexin, clindamycin, or erythromycin are recommended for more extensive or severe infections. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Cytology is a simple, rapid, and inexpensive diagnostic method to identify the causative agent 2
• Culture may be necessary to identify specific bacterial or fungal pathogens 1
• Wood's lamp examination can help identify certain fungal infections 1
• Dermoscopy can visualize characteristic features like black dot hair stubs 1

Treatment Algorithm Based on Severity

Mild Folliculitis

• First-line treatment: Topical clindamycin 1% solution/gel twice daily for 2-3 weeks 1
• Alternative topical option: Mupirocin ointment applied three times daily to affected areas 3
  • Patients should be re-evaluated if no clinical response within 3-5 days 3
  • Avoid using mupirocin on mucosal surfaces or in patients with moderate to severe renal impairment 3

Moderate to Severe Folliculitis

• First-line oral antibiotics (unless MRSA is suspected) 1:
  • Dicloxacillin
  • Cephalexin
  • Clindamycin
  • Erythromycin
• Treatment duration: 5-day course is as effective as 10 days if clinical improvement occurs 1
• For more severe or recurrent cases, extend treatment to 2-3 weeks 1
• For moderate to severe cases, tetracycline 500 mg twice daily for up to 4 months may be used 1

MRSA-Suspected Folliculitis

• Trimethoprim-sulfamethoxazole (SMX-TMP) 1-2 DS tablets twice daily
• Doxycycline 100 mg twice daily
• Clindamycin 300-450 mg three times daily
• For severe cases: vancomycin, linezolid, or daptomycin 1

Fungal Folliculitis

• Antifungal medications should be used when fungal etiology is confirmed 4
• Ketoconazole (oral) and econazole (topical) have shown effectiveness in treating Candida folliculitis 4

Folliculitis Decalvans (Scarring Alopecia)

• Oral antibiotics for moderate to severe inflammation
• Oral isotretinoin for mild active disease or refractory cases
• Consider short course of oral glucocorticosteroids for highly active disease 5

Special Considerations

Hormonal Treatment

For folliculitis associated with hormonal factors:

• Spironolactone (100-150 mg daily) shows 85% improvement rate in women with hormonally-influenced follicular disorders 1
• Combined oral contraceptives containing ethinyl estradiol with anti-androgenic progestins 1
• Metformin (500 mg 2-3 times daily) for women with polycystic ovarian syndrome features 1

Recurrent Folliculitis

• Prophylactic antibiotics for 4-52 weeks
• Intramuscular benzathine penicillin every 2-4 weeks 1
• For extensive disease or treatment failures: Clindamycin 300 mg twice daily with rifampicin 600 mg once daily for 10 weeks 1

Prevention Strategies

• Gentle skin care with pH5 neutral soaps and shampoos
• Use tepid water and pat skin dry
• Avoid greasy creams and synthetic clothing materials
• Consider chlorhexidine washes or antibacterial soaps
• Thoroughly launder clothing, towels, and bedding
• Bleach baths (1/4-1/2 cup of bleach per full bath) for prevention of recurrences 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 weeks of appropriate treatment 1

Treatment Pitfalls to Avoid

• Assuming all folliculitis is bacterial without proper diagnosis 2
• Prolonged use of antibiotics can result in overgrowth of nonsusceptible organisms, including fungi 3
• Failure to recognize non-infectious causes of folliculitis can lead to inappropriate treatment 6
• For scarring folliculitis (like folliculitis decalvans), treatment aims to control inflammation and prevent further hair loss; hair regrowth cannot be expected 5