How to manage folliculitis in a patient taking Rinvoq (upadacitinib)?

Management of Folliculitis Due to Rinvoq (Upadacitinib)

Immediate Assessment and Treatment Approach

For folliculitis developing in patients on Rinvoq, initiate topical clindamycin 1% solution or gel twice daily for at least 12 weeks as first-line therapy while continuing Rinvoq, and escalate to oral tetracycline 500 mg twice daily for 4-12 weeks if the folliculitis is moderate to severe or fails to respond to topical treatment. 1, 2

Severity-Based Treatment Algorithm

Mild Folliculitis (Grade 1):

• Continue Rinvoq at current dose 3
• Apply topical clindamycin 1% solution/gel twice daily for 12 weeks 1
• If signs of superadded infection develop, add alcohol-free topical antibiotics for at least 14 days 3
• Alternative topical options include erythromycin 1% cream or metronidazole 0.75% 2

Moderate Folliculitis (Grade 2):

• Continue Rinvoq at current dose as most cases improve within 2 weeks 3
• Escalate to oral tetracycline 500 mg twice daily for 4-12 weeks 1, 2
• Doxycycline and minocycline are more effective than tetracycline, though neither is superior to the other 1, 2
• Consider dose reduction or temporary interruption of Rinvoq only if folliculitis is prolonged or intolerable 3
• Add short-term topical corticosteroids (hydrocortisone 1-2.5% or eumovate ointment to face; betnovate, elocon, or dermovate ointment to body) for 2-3 weeks 3
• Combine systemic antibiotics with topical therapy to minimize bacterial resistance 1

Severe Folliculitis (Grade 3):

• Temporarily interrupt Rinvoq per FDA labeling guidance 4
• Initiate oral tetracycline 500 mg twice daily 1, 2
• Obtain bacterial cultures to guide antibiotic selection 2, 5
• For suspected MRSA, consider trimethoprim-sulfamethoxazole, doxycycline, or clindamycin 2
• Resume Rinvoq only once infection is controlled 4

Essential Preventive Measures

Skin Care Protocol:

• Cleanse with gentle pH-neutral soaps and tepid water 3, 1
• Pat skin dry after showering—avoid rubbing 3, 1
• Wear loose-fitting cotton clothing instead of synthetic materials 3, 1
• Apply hypoallergenic moisturizing emollients once daily, but avoid greasy creams in affected areas as they facilitate folliculitis development 3, 1
• Use shampoos that reduce scalp folliculitis risk such as ketoconazole, betadine, or ceanel 3

Critical Pitfalls to Avoid:

• Do not use topical acne medications without dermatologist supervision, as they may irritate and worsen the condition 3, 1
• Avoid prolonged topical steroid use, which can cause skin atrophy and paradoxically worsen folliculitis 3, 1
• Do not manipulate or pick at affected skin, as this increases infection risk 3, 5

Management of Recurrent or Refractory Cases

For Recurrent Folliculitis:

• Implement a 5-day decolonization regimen with intranasal mupirocin twice daily, daily chlorhexidine body washes, and decontamination of personal items 1, 2, 5
• Culture recurrent lesions and treat with a 5-10 day course of an antibiotic active against the isolated pathogen 1, 5
• Consider oral clindamycin 150 mg once daily for 3 months, which decreases subsequent infections by approximately 80% 2

For Refractory Cases:

• If no improvement after 8-12 weeks of oral tetracycline, consider combination therapy with oral clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks 2
• For localized lesions at risk of scarring, intralesional corticosteroids can provide rapid improvement 1, 2
• Consult dermatology for chronic grade 2 or higher folliculitis, as it can significantly impact quality of life 3

Special Considerations for Rinvoq

FDA Safety Warnings:

• Rinvoq increases risk of serious infections including cellulitis 4
• Monitor closely for signs of infection during treatment 4
• If herpes zoster develops (which appears more common in patients on JAK inhibitors in Japan), consider temporarily interrupting Rinvoq until the episode resolves 4
• Obtain bacterial swabs if secondary infection is suspected, as Staphylococcus aureus is the most frequently detected infectious agent 3, 5

Surgical Intervention:

• For large furuncles or abscesses, incision and drainage is the primary and most effective treatment 2, 5
• Perform thorough evacuation of pus and probe the cavity to break up loculations 2
• Obtain Gram stain and culture of purulent material to guide subsequent therapy 2, 5

Treatment Duration and Monitoring

• Initial systemic antibiotic duration is 5 days, with extension if no improvement occurs 1, 2
• Limit systemic antibiotic use to the shortest possible duration with re-evaluation at 3-4 months to minimize bacterial resistance 1, 2
• Reassess after 2 weeks or at any worsening of symptoms 2

Alternative Populations

• For pregnant women or children under 8 years who cannot take tetracyclines, use erythromycin or azithromycin instead 1, 2