What is the best treatment for an elderly male with a suspected ingrown hair (infected hair follicle) on his testicle, presenting with a bump and white head, accompanied by mild swelling in the upper groin area?

Treatment of Suspected Infected Hair Follicle on Scrotum in Elderly Male

For an elderly male with a suspected infected ingrown hair (folliculitis) on the testicle presenting as a bump with a white head and mild groin swelling, the best treatment is warm compresses, topical antiseptic cleansing, and close monitoring for progression, with urgent urological evaluation if symptoms worsen or if there is any concern for testicular pathology.

Critical First Step: Rule Out Testicular Pathology

While your description suggests a superficial skin infection, any scrotal mass or swelling in an elderly male requires careful evaluation to exclude testicular tumors or other serious conditions 1, 2. Key distinguishing features include:

• Superficial vs. deep location: A true ingrown hair or folliculitis will be clearly within the scrotal skin, mobile over the underlying testis, and not involving the testicular parenchyma itself 3
• Testicular examination: The underlying testis should be normal in size, consistency, and non-tender when palpated separately from the skin lesion 1
• Groin lymphadenopathy: Mild reactive inguinal swelling can occur with superficial skin infections, but significant or firm lymph nodes warrant further investigation 4

Red flags requiring immediate urological consultation include:

• Inability to clearly separate the lesion from the testis itself 5
• Firm, enlarged, or irregular testicular mass 2, 4
• Progressive pain or systemic symptoms (fever, malaise, weight loss) 6
• Persistent or enlarging groin masses 4

Management of Scrotal Folliculitis/Infected Ingrown Hair

Conservative Treatment Approach

For a clearly superficial infected hair follicle:

• Warm compresses: Apply 3-4 times daily for 10-15 minutes to promote drainage and resolution 7
• Gentle cleansing: Use mild antiseptic soap (chlorhexidine or povidone-iodine) twice daily 7
• Avoid manipulation: Do not squeeze or attempt to extract the hair, as this can worsen inflammation and spread infection 7
• Scrotal support: Supportive underwear can reduce discomfort and local irritation 7

When to Consider Antibiotics

Oral antibiotics are indicated if:

• The lesion shows signs of spreading cellulitis (expanding redness beyond the immediate follicle) 7
• Systemic symptoms develop (fever, chills) 7
• No improvement after 48-72 hours of conservative management 7
• The patient is immunocompromised or has diabetes 7

Antibiotic selection: Coverage for skin flora (Staphylococcus and Streptococcus species) with agents such as cephalexin 500 mg PO four times daily or dicloxacillin 500 mg PO four times daily for 7-10 days 7. If MRSA is suspected based on local prevalence or previous infections, trimethoprim-sulfamethoxazole or doxycycline may be appropriate 7.

Critical Pitfalls to Avoid

• Never assume a scrotal mass is benign without proper examination: Elderly men can develop testicular tumors, including germ cell tumors and lymphomas, which may present with associated hydroceles or scrotal swelling that can mask the underlying pathology 6, 2
• Testicular tumors in elderly men present at higher stages: Studies show that germ cell tumors in men ≥60 years have larger median tumor sizes (6 cm) and more frequent vascular invasion than in younger populations 4
• Lymphoma is common in this age group: Diffuse large B-cell lymphoma represents 33% of testicular tumors in elderly men and can present with scrotal swelling 2

Follow-up Algorithm

If symptoms improve with conservative treatment:

• Continue warm compresses until complete resolution 7
• Monitor for recurrence 7
• Consider scrotal hygiene education to prevent future episodes 7

If symptoms persist or worsen after 48-72 hours:

• Perform or arrange scrotal ultrasound to evaluate testicular parenchyma and rule out abscess, epididymitis, or testicular mass 1, 3
• Consider urological referral for further evaluation 1

If groin swelling persists or enlarges:

• Ultrasound evaluation of inguinal lymph nodes may be warranted to exclude malignant lymphadenopathy 4

Special Considerations in Elderly Males

• Comorbidities: Elderly patients with diabetes, immunosuppression, or vascular disease may have impaired wound healing and higher infection risk, warranting lower threshold for antibiotic therapy 8
• Testicular cancer risk: While germ cell tumors peak in younger men, they do occur in elderly patients (4% of all testicular cancers), and seminoma is the most common histology in this age group 8, 2
• Maintain high index of suspicion: Any persistent or atypical scrotal lesion should prompt imaging and specialist evaluation 5, 6