What is the treatment for Folliculitis?

Treatment for Folliculitis

The first-line treatment for folliculitis includes using gentle pH-neutral soaps with tepid water for cleansing, patting the skin dry after showering, and applying topical clindamycin 1% solution/gel twice daily for 12 weeks for mild cases. 1

Initial Management Approach

• For mild folliculitis, use gentle pH-neutral soaps with tepid water, pat the skin dry after showering, and wear loose-fitting cotton clothing to reduce friction and moisture 2, 1
• Apply topical clindamycin 1% solution/gel twice daily for mild cases as first-line therapy 1
• Avoid greasy creams in affected areas and manipulation of the skin to reduce risk of secondary infection 2, 1
• Avoid using topical acne medications without dermatologist supervision as they may irritate and worsen the condition 2, 1

Moderate to Severe Cases

• For widespread folliculitis or cases with systemic symptoms, oral antibiotics should be considered 2
• Oral tetracycline 500 mg twice daily for 4 months is recommended for more widespread disease or cases with inadequate response to topical therapy 1
• For suspected or confirmed Staphylococcus aureus infection with systemic symptoms, antibiotics active against MRSA may be necessary 2
• If no improvement occurs with tetracycline, combination therapy with oral clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks should be considered 1

Management of Specific Types of Folliculitis

• For folliculitis decalvans (a form of scarring alopecia), oral antibiotics are recommended for moderate to severe inflammation, with oral isotretinoin as first-line therapy for mild active disease 3
• Cytology can be a valuable diagnostic tool to identify the causative agent (bacterial, fungal, viral, or parasitic) before initiating treatment 4
• For fungal folliculitis, such as Candida folliculitis, antifungal treatment with oral ketoconazole and topical antifungals may be effective 5

Recurrent Folliculitis Management

• For recurrent cases, search for local causes such as hidradenitis suppurativa or foreign material 2
• Consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items 2, 1
• Culture recurrent abscesses and treat with a 5-10 day course of an antibiotic active against the isolated pathogen 2
• Bacterial cultures should be obtained for recurrent or treatment-resistant cases to guide antibiotic selection 1

Adjunctive Therapies

• For localized lesions at risk of scarring, intralesional corticosteroids can provide rapid improvement in inflammation and pain 1
• Topical corticosteroids of mild to moderate potency can be used short-term to reduce inflammation 2, 1
• Incision and drainage is the recommended treatment for large furuncles or abscesses 2

Common Pitfalls to Avoid

• Avoid prolonged use of topical steroids as they may cause skin atrophy 2, 1
• Avoid assuming all folliculitis is bacterial in origin, as there are many non-infectious causes that require different treatment approaches 4, 6
• Don't overlook the need for bacterial cultures in recurrent or treatment-resistant cases, as this can guide appropriate antibiotic selection 1
• Remember that the presence of superficial pustules does not always imply an infectious origin 7

Treatment Algorithm

1. Start with topical clindamycin 1% solution/gel twice daily for mild cases 1
2. If inadequate response after 4-6 weeks, switch to oral tetracycline 500 mg twice daily 1
3. For non-responders after 8-12 weeks, consider clindamycin 300 mg twice daily with rifampicin 600 mg once daily 1
4. For recurrent cases, obtain bacterial cultures and consider decolonization protocols 2, 1