What antibiotics are used to treat folliculitis?

Antibiotics for Folliculitis

First-Line Treatment Approach

For simple, superficial folliculitis, topical therapy is preferred over systemic antibiotics, with topical benzoyl peroxide as the first-line nonantibiotic option. 1

• Topical mupirocin or clindamycin are appropriate topical antibiotic options when nonantibiotic therapy fails 1
• Simple folliculitis is typically self-limited and does not require systemic antibiotics in most cases 1
• The distinction between superficial folliculitis (pustule at follicle opening) and deep folliculitis (extending beyond the follicle as furuncles) is clinically crucial for treatment decisions 2

When Systemic Antibiotics Are Indicated

Oral antibiotics should be reserved for treatment-resistant cases or deep folliculitis that has progressed to furuncles or carbuncles. 1

Oral Antibiotic Options

• Cephalexin is an appropriate first-line oral option for treatment-resistant folliculitis 1
• Dicloxacillin is equally appropriate as first-line oral therapy 1
• Both agents provide excellent coverage against Staphylococcus aureus, the primary pathogen in folliculitis 1, 2

MRSA Considerations

• Methicillin-resistant S. aureus (MRSA) coverage should be considered specifically for patients with infections that have not improved with standard treatment 1
• For suspected MRSA folliculitis, clindamycin 300-450 mg orally three times daily provides coverage if local resistance rates are <10% 3
• Trimethoprim-sulfamethoxazole is an alternative MRSA-active agent for resistant cases 3

Special Situations

Recurrent Folliculitis

• Nasal carriage of S. aureus should be sought in patients with recurrent folliculitis and their family members 4
• Topical mupirocin applied to the anterior nares of patients and household carriers controls recurrent infection more effectively than systemic antibiotics alone 4
• A 5-day decolonization regimen of intranasal mupirocin twice daily, daily chlorhexidine washes, and daily decontamination of personal items should be considered for recurrent S. aureus infection 5

Furuncles and Carbuncles

Incision and drainage is the recommended primary treatment for furuncles and carbuncles, with systemic antibiotics reserved for specific indications. 5

• Systemic antimicrobials are usually unnecessary unless fever or other evidence of systemic infection is present 5
• Antibiotics directed against S. aureus should be administered as an adjunct to incision and drainage based on the presence of SIRS (temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12,000 or <400 cells/µL) 5
• An antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have markedly impaired host defenses and in patients with SIRS 5

Treatment Duration

• For recurrent abscesses requiring antibiotics, a 5- to 10-day course of an antibiotic active against the pathogen isolated is recommended 5
• Treatment duration should be guided by clinical response and culture results when available 5

Critical Pitfalls to Avoid

• Do not reflexively prescribe systemic antibiotics for simple superficial folliculitis, as most cases are self-limited 1
• Do not use topical antibiotics as first-line therapy when nonantibiotic options like benzoyl peroxide are available 1
• Do not forget to search for and address predisposing factors such as follicular occlusion, overhydration, or mechanical irritation 2
• Do not overlook the need for surgical drainage when folliculitis has progressed to furuncles or carbuncles, as antibiotics alone are insufficient 5, 2