Treatment and prevention of folliculitis

Local measures:

• cleaning - use chlorhexidine and apply saline or aluminium subacetate soaks/compresses for 15 minutes, twice daily. Open the larger pustules and trim away any necrotic tissue. Anhydrous ethyl alcohol containing 6.25% aluminium chloride may be helpful.

General measures:

• systemic antibiotics, e.g. flucloxacillin or clarithromycin (if penicillin-allergic) - only if local treatment is ineffective; the infection is severe; or has become complicated or involves the upper lip, nose or eyes from which a cavernous sinus thrombosis may develop
  • in general, a 7-day course of antibiotic treatment is indicated for acute folliculitis (1,2,3,4)
    • for some cases of folliculitis, a course of oral antibiotics may be administered over 7 to 10 days (5)
      
      
  • chronic folliculitis may require prolonged antibiotic treatment, e.g. oxytetracycline for 6-8 weeks (however, in cases of chronic folliculitis it is important to swab lesions and consult with local microbiological advice regarding antibiotic prescribing) (6)
    
    
  • for antibiotic-resistant S. aureus, then consult local guidance
    • clindamycin, tetracyclines, trimethoprim-sulfamethoxazole, linezolid, or glycopeptide (e.g. parenteral vancomycin) may be used (7)
      
      
• topical 2% mupirocin - 3 times daily and supported with dressings. Particularly valuable in eliminating primary or secondary infection.

Specific forms of folliculitis:

• hot tub folliculitis - pseudomonas folliculitis is a benign, self-limited disorder (2). Showering after exposure to contaminated water does not seem to prevent the disease
  • hot water, a high pH, and low chlorine levels all predispose to infection - pseudomonas folliculitis can be prevented by proper maintenance and chlorination of pools, hot tubs, whirlpools, and spas to decrease the population of P. aeruginosa
  • antibiotic treatment with ciprofloxacin may be used
    • use of systemic antimicrobial agents should be considered in patients with fever and constitutional symptoms or in patients with resistant disease (3)
      
      
• gram-negative folliculitis
  • sometimes failure to respond to antibiotic therapy is due to the development of gram-negative folliculitis
    • high-dose trimethoprim - 300mg bd in adults - is the antibiotic of choice in these situations (3)
    • isotretinoin has been successfully used to treat different forms of folliculitis, including gram-negative folliculitis and HIV-associated eosinophilic folliculitis (4)

Prevention:

• correct precipitating factors:
  • systemic, e.g. diabetes mellitus
  • local, e.g. irritations, discharges

References:

1. Prescriber (2004); 15 (13): 35-40.
2. Yu Y et al. Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa. J Am Acad Dermatol. 2007 Oct;57(4):596-600. Epub 2007 Jul 19.
3. Pulse (3/10/07):49.
4. Dermatology in Practice 2007;15(4):26-28.
5. Laureano AC et al. Facial bacterial infections: folliculitis. Clinics in Dermatology 2014;2(6):711-4.
6. Personal communication (23/5/12). Dr P Kenyon (GPSI Dermatology, Rugby Hospital).
7. Nagaraju U et al. Methicillin resistant Staphylococcus aureus in community-acquired pyoderma. International Journal of Dermatology 2004;43(6):412-4.