What are the treatment options for folliculitis versus impetigo?

Treatment Differences Between Folliculitis and Impetigo

Key Distinction in Management

Folliculitis requires incision and drainage for large lesions (furuncles/carbuncles) as the primary treatment, while impetigo is treated with topical or oral antibiotics without surgical intervention. 1

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Impetigo Treatment

First-Line Therapy

• Topical mupirocin or retapamulin applied twice daily for 5 days is as effective as oral antibiotics for limited impetigo 1, 2
• Retapamulin is FDA-approved for impetigo caused by S. aureus (methicillin-susceptible only) or Streptococcus pyogenes in patients ≥9 months old 2
• Apply a thin layer to affected areas up to 100 cm² in adults or 2% total body surface area in pediatric patients 2

When to Use Systemic Antibiotics

• Systemic therapy is preferred for patients with numerous lesions or in outbreaks affecting multiple people to decrease transmission 1
• Oral penicillinase-resistant penicillin or first-generation cephalosporins (e.g., cephalexin) are usually effective as most staphylococcal isolates from impetigo are methicillin-susceptible 1
• For penicillin-allergic patients or MRSA infections: doxycycline, clindamycin, or trimethoprim-sulfamethoxazole 1
• When streptococci alone are isolated, penicillin is the drug of choice, with macrolides or clindamycin for penicillin-allergic patients 1

Clinical Pearls

• Cultures of vesicle fluid, pus, or erosions establish the causative organism 1
• Unless cultures yield streptococci alone, antimicrobial therapy should cover both S. aureus and streptococci 1
• The treated area may be covered with a sterile bandage or gauze dressing if desired 2

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Folliculitis Treatment

Mild Superficial Folliculitis

• Topical clindamycin 1% solution/gel applied twice daily for 12 weeks is first-line therapy for mild cases 3, 4
• Alternative topical options include erythromycin 1% cream or metronidazole 0.75% 4
• Use gentle pH-neutral soaps with tepid water, pat skin dry, and wear loose-fitting clothing to reduce friction 3, 4
• Avoid greasy creams and skin manipulation to reduce secondary infection risk 3, 4

Moderate to Severe or Widespread Folliculitis

• Oral tetracycline 500 mg twice daily for 4-12 weeks is recommended for widespread disease or inadequate response to topical therapy 3, 4
• Doxycycline 100 mg twice daily or minocycline 100 mg twice daily for 2-4 weeks are more effective than tetracycline 4, 5
• For suspected or confirmed S. aureus infection with systemic symptoms, antibiotics active against MRSA (trimethoprim-sulfamethoxazole, doxycycline, or clindamycin) may be necessary 3, 4

Refractory or Recurrent Cases

• For non-responders to tetracycline after 8-12 weeks, combination therapy with oral clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks should be considered 3, 4
• Implement a 5-day decolonization regimen with intranasal mupirocin twice daily, daily chlorhexidine washes, and decontamination of personal items (towels, sheets, clothes) 3, 4, 5
• Applying mupirocin ointment twice daily to anterior nares for the first 5 days of each month reduces recurrences by approximately 50% 4
• Oral clindamycin 150 mg once daily for 3 months decreases subsequent infections by approximately 80% 4
• Culture recurrent lesions and treat with a 5-10 day course of an antibiotic active against the isolated pathogen 3

Furuncles and Carbuncles (Deep Folliculitis)

• Incision and drainage is the primary and most effective treatment for furuncles and carbuncles 1, 4, 5
• Perform incision, thorough evacuation of pus, and probe the cavity to break up loculations 4
• Obtain Gram stain and culture of purulent material to guide subsequent therapy 1, 4
• Simply covering the surgical site with a dry dressing is usually most effective; packing causes more pain without improving healing 1
• Systemic antibiotics are usually unnecessary unless extensive surrounding cellulitis, fever, or SIRS criteria are present 1

SIRS Criteria for Antibiotic Use

• Temperature >38°C or <36°C 1
• Tachypnea >24 breaths/minute 1
• Tachycardia >90 beats/minute 1
• White blood cell count >12,000 or <4,000 cells/µL 1

Adjunctive Therapies

• Moist heat application (warm compresses 3-4 times daily) can promote drainage of small lesions 4, 5
• Topical corticosteroids of mild to moderate potency can be used short-term to reduce inflammation 3, 4
• For localized lesions at risk of scarring, intralesional corticosteroids can provide rapid improvement 3, 4

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Critical Differences Summary

Feature	Impetigo	Folliculitis
Primary Treatment	Topical antibiotics (mupirocin/retapamulin) [1,2]	Topical clindamycin for mild; oral tetracyclines for moderate-severe [3,4]
Surgical Intervention	Not indicated [1]	Incision and drainage for furuncles/carbuncles [1,4]
Duration	5 days [1,2]	4-12 weeks for oral therapy [3,4]
Systemic Antibiotics	For numerous lesions or outbreaks [1]	For widespread disease, SIRS, or inadequate topical response [3,4]
Decolonization	Not routinely recommended [1]	Essential for recurrent cases [3,4,5]

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Common Pitfalls to Avoid

For Impetigo

• Don't perform incision and drainage—this is not indicated for impetigo 1
• Don't use topical antibiotics alone when numerous lesions are present; systemic therapy is more appropriate 1
• Don't forget to culture if treatment fails, as this may identify MRSA 1

For Folliculitis

• Don't use topical acne medications without dermatologist supervision as they may irritate and worsen the condition 3, 4
• Avoid prolonged use of topical steroids as they may cause skin atrophy and can actually cause folliculitis as a side effect 3, 4
• Don't neglect incision and drainage for large furuncles or carbuncles—this is the primary treatment 1, 4
• Don't miss tinea capitis in the differential diagnosis, especially with scalp involvement and treatment failure, as it can present with pustular lesions resembling folliculitis 3, 6
• Don't continue topical treatments alone when they've already proven ineffective; escalate to systemic therapy 5
• MRSA is an unusual cause of typical folliculitis, so routine MRSA coverage is not necessary unless there are risk factors or treatment failure 4

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Special Considerations

For Immunocompromised Patients

• Longer courses of treatment and closer follow-up may be necessary 5
• Lower threshold for systemic antibiotics with MRSA coverage 3

For Pregnant Patients or Children <8 Years

• Avoid tetracyclines; use erythromycin or azithromycin instead 4

When MRSA is Suspected

• For impetigo: use trimethoprim-sulfamethoxazole, doxycycline, or clindamycin 1
• For folliculitis: same agents, or consider combination therapy with clindamycin plus rifampicin 3, 4