What is the treatment for folliculitis?

Treatment for Folliculitis

The most effective treatment for folliculitis includes gentle cleansing with pH-neutral soaps, avoiding skin irritation, and using appropriate topical or systemic antimicrobials based on severity. 1

Initial Management for Mild Folliculitis

• Use gentle pH-neutral soaps and tepid water for cleansing the affected area, pat the skin dry after showering, and wear loose-fitting, fine cotton clothes to reduce friction and moisture 2, 1
• Avoid greasy creams as they might facilitate the development of folliculitis due to their occlusive properties 2, 1
• Avoid manipulation of skin in the affected area to reduce the risk of secondary infection 2
• Apply topical antibiotics such as clindamycin, mupirocin, or fusidic acid to affected areas 1, 3
• For shaving-related folliculitis, ensure shaving is done carefully with adequate lubrication to minimize trauma 2

For Moderate to Severe Cases

• Consider oral antibiotics for widespread folliculitis or cases with systemic symptoms 1, 4
• First-line systemic antibiotics include:
  • Tetracyclines (doxycycline 100mg twice daily or minocycline 100mg twice daily) for their anti-inflammatory and antimicrobial effects 1, 3
  • Cephalosporins (cefadroxil, cefdinir, cefalexin) or clindamycin for gram-positive coverage 4
• For suspected or confirmed Staphylococcus aureus infection with systemic symptoms, antibiotics active against MRSA may be necessary 1, 4
• Duration of treatment typically ranges from 7-10 days, but may extend to 2-4 weeks for recurrent cases 4

For Recurrent or Refractory Folliculitis

• Consider oral isotretinoin (0.5-1 mg/kg/day) as it has shown 90% stable remission rates in studies of folliculitis decalvans and may be effective for other types of recurrent folliculitis 5
• Search for local causes such as hidradenitis suppurativa or foreign material 1
• Consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items 1
• Culture recurrent lesions and treat with antibiotics active against the isolated pathogen 1, 4
• For folliculitis decalvans (a specific type of scarring folliculitis), oral fusidic acid 500mg three times daily has shown good results 3

Special Considerations

• If secondary infection occurs, bacterial swabs should be taken and targeted antibiotic treatment started, as Staphylococcus aureus is the most frequently detected infectious agent 2
• Incision and drainage is recommended for large furuncles or abscesses 1
• For folliculitis related to EGFR inhibitor treatment (common in cancer patients), specific management protocols including tetracyclines are recommended 2

Alternative Treatments for Resistant Cases

• Photodynamic therapy may be beneficial for recalcitrant cases 2, 6
• For refractory cases, consider topical corticosteroids of mild to moderate potency for short-term use to reduce inflammation 1
• Biologics (particularly adalimumab) or JAK inhibitors may be considered for severe, recalcitrant folliculitis decalvans 6

Common Pitfalls to Avoid

• Avoid topical acne medications without dermatologist supervision, as they may irritate and worsen the condition 2
• Avoid prolonged use of topical steroids as they may cause skin atrophy if used inadequately 2
• Do not rely solely on antibiotics for chronic folliculitis as resistance may develop; consider addressing underlying causes 5
• Avoid hot blow-drying of hair and tight clothing that can exacerbate folliculitis 2