What is the appropriate management of scalp folliculitis?

Management of Scalp Folliculitis

For scalp folliculitis, treatment depends on severity: mild cases require only warm compresses, while moderate-to-severe cases need incision and drainage plus systemic antibiotics active against Staphylococcus aureus, with consideration for MRSA coverage based on local resistance patterns and systemic signs of infection. 1

Initial Assessment and Diagnosis

Critical first step: Distinguish bacterial folliculitis from fungal tinea capitis, as management differs fundamentally. 1

• Bacterial folliculitis presents with superficial pustules, inflammatory nodules with overlying pustules through which hair emerges, and pus limited to the epidermis 1
• Tinea capitis (fungal) presents with patchy alopecia, scaling, and may show scattered pustules or low-grade folliculitis with painful regional lymphadenopathy 1
• Obtain cultures (Gram stain and bacterial culture) from pustules or abscesses to guide antibiotic selection and identify MRSA 1
• For suspected tinea capitis, obtain fungal cultures via scalp brushings, hair plucking, or scalpel scraping 1

Treatment Algorithm Based on Severity

Mild Folliculitis (Superficial, Limited Lesions)

• Moist heat application to promote spontaneous drainage 1
• No systemic antibiotics required unless fever or extensive surrounding cellulitis develops 1
• Topical mupirocin or retapamulin may be considered for localized disease 1

Moderate-to-Severe Folliculitis (Multiple Lesions, Furuncles, or Carbuncles)

Incision and drainage is the primary treatment for all furuncles, carbuncles, and abscesses 1

• Simply cover the surgical site with dry dressing (packing not necessary and causes more pain) 1
• Add systemic antibiotics if any of the following present: 1
  • SIRS criteria (temperature >38°C or <36°C, tachycardia >90 bpm, tachypnea >24 breaths/min, WBC >12,000 or <4,000 cells/µL)
  • Extensive surrounding cellulitis
  • Fever or systemic symptoms
  • Multiple lesions
  • Severely impaired host defenses

Antibiotic Selection

For MSSA (methicillin-susceptible S. aureus): 1

• First-line: Dicloxacillin or cephalexin
• Alternative: Clindamycin 150 mg daily

For MRSA coverage (required if local resistance >10-15% or patient has risk factors): 1

• Trimethoprim-sulfamethoxazole
• Doxycycline or minocycline
• Clindamycin (if susceptible)
• Linezolid (for severe cases)

Duration: 5-10 days for acute infection 1

Recurrent Scalp Folliculitis

For patients with recurrent episodes, implement decolonization strategy: 1

• Intranasal mupirocin ointment twice daily for first 5 days of each month (reduces recurrences by ~50%) 1
• Oral clindamycin 150 mg daily for 3 months for susceptible S. aureus (decreases subsequent infections by ~80%) 1
• Daily chlorhexidine washes of the scalp 1
• Daily decontamination of personal items (towels, sheets, pillowcases) 1
• Culture recurrent lesions early to guide targeted therapy 1

Special Considerations and Pitfalls

Common diagnostic errors to avoid:

• Do not misdiagnose kerion (severe inflammatory tinea capitis) as bacterial abscess - kerion presents as painful, boggy inflammatory mass with pustules and requires systemic antifungal therapy, not just antibiotics 1
• Consider secondary bacterial superinfection in tinea capitis with pustules - may require both antifungal and antibacterial therapy 1
• Folliculitis decalvans is a chronic scarring bacterial folliculitis caused by S. aureus requiring prolonged oral antibiotics (not just short courses) 2, 3, 4

When systemic antibiotics are NOT needed: 1

• Small, isolated furuncles without systemic signs
• Simple inflamed epidermoid cysts (inflammation is chemical, not infectious)
• After adequate incision and drainage in immunocompetent patients without SIRS

Hygiene measures during treatment: 1

• Bathing with chlorhexidine or antibacterial soaps
• Thorough laundering of clothing, towels, and bedding
• Separate use of towels and washcloths
• Avoid manipulation or picking at lesions

For inflammatory tinea capitis variants: Systemic antifungal therapy is mandatory (topical agents alone are insufficient), and oral corticosteroids may be added for severe kerion to reduce scarring risk 1