What is the treatment for suppurative folliculitis?

Treatment of Suppurative Folliculitis

For suppurative folliculitis, incision and drainage is the primary treatment for large furuncles and carbuncles, with systemic antibiotics reserved only for patients with fever, systemic inflammatory response syndrome (SIRS), or markedly impaired host defenses. 1

Initial Assessment and Diagnosis

• Distinguish the type of folliculitis based on clinical presentation: superficial folliculitis (pus limited to epidermis) versus furuncles (suppuration extending into subcutaneous tissue with abscess formation) versus carbuncles (coalescent inflammatory mass involving multiple adjacent follicles) 1
• Obtain Gram stain and culture from carbuncles and abscesses to guide antibiotic selection, though treatment without these studies is reasonable in typical cases 1
• Assess for SIRS criteria: temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12,000 or <4,000 cells/µL 1

Primary Treatment Approach

Surgical Management

• Perform incision and drainage for all large furuncles and carbuncles—this is the definitive treatment 1
• Cover the surgical site with a dry sterile dressing after drainage; packing causes more pain without improving healing compared to simple gauze coverage 1
• Avoid needle aspiration as it has only 25% success rate overall and <10% success with MRSA infections 1

When to Add Antibiotics

Systemic antibiotics are NOT routinely needed unless specific criteria are met 1:

• Presence of SIRS (see criteria above) 1
• Markedly impaired host defenses (immunocompromised patients, diabetes, HIV) 1
• Fever or other evidence of systemic infection 1

Antibiotic Selection When Indicated

For MRSA Coverage (when antibiotics are needed)

• Use an antibiotic active against MRSA in patients with carbuncles/abscesses who meet the above criteria 1
• Options include trimethoprim-sulfamethoxazole, doxycycline, or clindamycin based on local resistance patterns 1

For Superficial Folliculitis

• Topical mupirocin or retapamulin is as effective as oral antimicrobials for impetigo and superficial infections 1
• Apply mupirocin ointment three times daily to affected areas, with gauze dressing optional 2
• Re-evaluate patients not responding within 3-5 days of topical therapy 2

Special Circumstances

Recurrent Suppurative Folliculitis

• Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material 1
• Drain and culture early in the course of recurrent infections 1
• Treat with 5-10 day course of antibiotic active against isolated pathogen 1
• Consider 5-day decolonization regimen for recurrent S. aureus: intranasal mupirocin twice daily, daily chlorhexidine washes, and daily decontamination of personal items 1

Pseudomonas Folliculitis (Hot Tub Folliculitis)

• Typically resolves spontaneously within 7-10 days without treatment 3
• Presents 8-48 hours after contaminated water exposure with pruritic papulopustules on trunk and extremities 3

Critical Pitfalls to Avoid

• Do not routinely prescribe antibiotics for simple furuncles or carbuncles without SIRS or immunocompromise—incision and drainage alone is sufficient 1
• Do not attempt needle aspiration as primary treatment; it has unacceptably low success rates 1
• Do not pack wounds after incision and drainage; simple dry dressing is superior for pain and healing 1
• Do not obtain blood cultures or tissue biopsies routinely in immunocompetent patients with typical presentations 1