How to approach Platelet-Rich Plasma (PRP) therapy in a patient with active chronic folliculitis presenting with 2-3 bumps at a time?

Managing PRP Therapy in Active Chronic Folliculitis

Defer PRP treatment until the active folliculitis is completely controlled with appropriate antimicrobial and anti-inflammatory therapy, as performing PRP injections into actively inflamed follicles risks worsening infection, spreading bacteria, and causing treatment failure.

Critical Safety Concern: Active Infection is an Absolute Contraindication

• Active folliculitis represents an active infection/inflammation of hair follicles that must be resolved before any invasive scalp procedure 1
• Injecting PRP into infected tissue can spread bacteria deeper into the dermis, potentially causing abscess formation or cellulitis 1
• The trauma from multiple needle punctures (spaced 1 cm apart across the treatment area) would disrupt infected follicles and worsen the inflammatory process 1

Step 1: Treat the Folliculitis First

For Mild Active Folliculitis (2-3 bumps):

• Initiate oral tetracyclines (doxycycline or minocycline) for their anti-inflammatory and immunomodulating effects 1
• Apply topical antibiotics if bacterial infection is suspected (Staphylococcus aureus is most common) 1
• Consider topical antiseptics like povidone-iodine solution for 7 days 2
• Avoid manipulation of lesions to prevent spreading infection 1

For Moderate to Severe or Refractory Cases:

• Oral antibiotics remain first-line for moderate/severe inflammation 3
• Consider oral isotretinoin for persistent inflammatory lesions or refractory disease 3
• Topical or intralesional corticosteroids can be added to systemic treatment 3
• For truly refractory cases, biologics (preferably adalimumab) may be effective 3, 4

Step 2: Confirm Complete Resolution Before PRP

Clinical Criteria for Clearance:

• No active pustules, crusts, or perifollicular erythema present 3
• No pain, tenderness, or warmth over affected areas 1
• Wait minimum 2-4 weeks after complete clinical resolution before considering PRP (based on wound healing principles and infection clearance)

Pre-Treatment Preparation:

• Patient must shampoo and detangle hair before session with no styling products applied 1
• Scalp must be completely clean and free of any signs of active infection 1
• Take excellent before-and-after photographs for documentation 1

Step 3: Standard PRP Protocol Once Cleared

Treatment Protocol:

• Administer 3 treatment sessions spaced exactly one month apart 1, 5
• Deliver 5-7 mL PRP per session (0.05-0.1 mL/cm²) 1
• Use 30-gauge × 4 mm needles with point-by-point injection at 90-degree angle, 2-4 mm depth 1
• Space injections 1 cm apart across mapped areas 1
• Apply pharmaceutical-grade topical anesthetic before injection 1

PRP Preparation:

• Use manual double-spin method targeting 1.0-1.5 million platelets per microliter 1, 6
• Do NOT activate PRP—nonactivated PRP shows 31% greater increases in hair count and density 6, 5

Concurrent Therapy:

• Combine with topical minoxidil 5% at 1 mL twice daily throughout treatment and beyond for superior outcomes 6, 5
• Consider adding finasteride as background therapy 6, 5

Maintenance Phase:

• Maintenance PRP injections every 6 months are required to sustain results long-term 1, 6

Common Pitfalls to Avoid

• Never perform PRP on active infection—this is the most critical error that can lead to serious complications 1
• Do not rush treatment; ensure complete resolution of folliculitis before proceeding 3
• Avoid using activated PRP, as nonactivated formulations are significantly more effective 6, 5
• Do not skip maintenance treatments, as discontinuation results in loss of gains 6, 5
• Ensure proper aseptic technique during injection to prevent introducing new infection 1

Monitoring During Treatment

• Watch for any recurrence of folliculitis during the PRP treatment course 3
• If folliculitis recurs during PRP therapy, immediately pause PRP and reinitiate antimicrobial treatment 3
• Pain during injection is expected and manageable with topical anesthetics, but new-onset pain between sessions may indicate infection 5, 7