What is the treatment for folliculitis?

Treatment for Folliculitis

For folliculitis, first-line treatment includes topical clindamycin 1% solution/gel applied twice daily for mild cases, while oral tetracycline 500 mg twice daily is recommended for moderate to severe or widespread cases. 1

Initial Management Approach

• Use gentle pH-neutral soaps and tepid water for cleansing affected areas, pat the skin dry after showering, and wear loose-fitting, fine cotton clothing to reduce friction and moisture 2, 1
• Apply topical clindamycin 1% solution/gel twice daily for 12 weeks as first-line therapy for mild cases 1
• Avoid greasy creams in affected areas as they might facilitate folliculitis development due to their occlusive properties 3, 1
• Avoid manipulation of skin in the affected area to reduce risk of secondary infection 3, 2

For Moderate to Severe Cases

• Oral tetracycline 500 mg twice daily for 4 months is recommended for 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 after 8-12 weeks, consider combination therapy with oral clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks 1

For Secondary Infections

• If secondary infection occurs, bacterial swabs should be taken and targeted antibiotic treatment started, as Staphylococcus aureus is the most frequently detected infectious agent 3, 2
• Incision and drainage is the recommended treatment for large furuncles or abscesses 2
• For topical treatment of impetigo or secondarily infected lesions, mupirocin ointment can be applied to the affected area three times daily, with re-evaluation if no clinical response within 3-5 days 4

For Recurrent Folliculitis

• 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

For Refractory Cases

• For localized lesions at risk of scarring, intralesional corticosteroids can provide rapid improvement in inflammation and pain 1
• Consider oral isotretinoin for mild active disease with perifollicular erythema and hyperkeratosis (without pustules or crusts) or for refractory disease 5
• For folliculitis decalvans (a severe form of scarring alopecia), biologics (preferably adalimumab), JAK inhibitors, oral dapsone, hydroxychloroquine, or cyclosporine may be effective in treatment-resistant cases 5

Adjunctive Therapies

• Topical corticosteroids of mild to moderate potency can be used short-term to reduce inflammation, but should only be used under dermatologist supervision 2, 1
• For fungal folliculitis, oral ketoconazole and topical antifungals like econazole may be effective 6

Common Pitfalls to Avoid

• Avoid using topical acne medications without dermatologist supervision as they may irritate and worsen the condition 3, 2, 1
• Avoid prolonged use of topical steroids as they may cause perioral dermatitis and skin atrophy if used inadequately 3, 1
• Be aware that not all folliculitis is bacterial - cytology can help identify fungal, viral, and parasitic causes that would require different treatment approaches 7
• When using mupirocin ointment, avoid use on mucosal surfaces and be cautious in patients with moderate to severe renal impairment due to potential absorption of polyethylene glycol 4

Treatment Algorithm

1. For mild folliculitis: Start with topical clindamycin 1% solution/gel twice daily 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
5. For refractory cases: Consider oral isotretinoin or other systemic agents under specialist supervision 5