What is the treatment for folliculitis?

Treatment for Folliculitis

First-Line Treatment Based on Severity

For mild folliculitis, start with topical clindamycin 1% solution or gel applied twice daily for 12 weeks, combined with gentle skin care measures. 1

Mild Cases

• Topical clindamycin 1% solution/gel twice daily for 12 weeks is the recommended first-line therapy 1
• Use gentle pH-neutral soaps with tepid water for cleansing 1
• Pat skin dry after showering and wear loose-fitting cotton clothing to reduce friction and moisture 1
• Avoid greasy creams in affected areas and do not manipulate the skin to reduce secondary infection risk 1

Moderate to Severe Cases

• If inadequate response to topical therapy after 4-6 weeks, switch to oral tetracycline 500 mg twice daily for 4 months 1
• Doxycycline and minocycline are more effective than tetracycline, though neither is superior to the other 1
• Systemic antibiotics should be used in combination with topical therapy to minimize bacterial resistance 1
• The recommended initial duration for systemic antibiotics is 5 days, but extend treatment if infection has not improved 1

MRSA Coverage

• For suspected or confirmed MRSA, use antibiotics with MRSA coverage such as trimethoprim-sulfamethoxazole 1
• First-generation cephalosporins (e.g., cephalexin 250-500 mg four times daily) are appropriate for methicillin-susceptible S. aureus 2
• Clindamycin 300-450 mg three times daily is recommended for penicillin-allergic patients 2

Refractory Cases

• If no improvement with tetracycline after 8-12 weeks, use combination therapy with oral clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks 1
• 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 1

Special Populations

• Erythromycin or azithromycin can be used in patients who cannot take tetracyclines, such as pregnant women or children under 8 years 1
• Doxycycline 100 mg twice daily is recommended for adults and children over 8 years old 2

Recurrent Folliculitis Management

• Obtain bacterial cultures for recurrent or treatment-resistant cases to guide antibiotic selection 1
• Consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items 1, 2
• Search for local causes such as hidradenitis suppurativa or foreign material 2
• For recurrent furunculosis caused by susceptible S. aureus, a single oral daily dose of 150 mg of clindamycin for 3 months can decrease subsequent infections by approximately 80% 2

Large Furuncles or Abscesses

• Incision and drainage is the recommended treatment for large furuncles or abscesses 2
• Perform Gram stain and culture of pus to guide antibiotic therapy 2
• Apply moist heat to promote drainage of small furuncles 2

Monitoring and Duration

• Systemic antibiotic use should be limited to the shortest possible duration with re-evaluation at 3-4 months to minimize bacterial resistance 1
• Treatment should be extended beyond resolution of manifestations to avoid recurrences 3

Critical Pitfalls to Avoid

• Do not use topical acne medications without dermatologist supervision as they may irritate and worsen the condition 1, 2
• Avoid prolonged use of topical steroids as they may cause skin atrophy 1, 2
• Do not neglect to consider underlying conditions that may predispose to recurrent folliculitis, such as diabetes or HIV 2
• Remember that systemic antibiotics are rarely necessary for simple abscesses unless there are multiple lesions, extensive surrounding cellulitis, or severe systemic manifestations 2