Skin Infections

Introduction to Folliculitis

• Folliculitis is a skin infection that can be caused by bacterial or fungal pathogens, and its treatment depends on the severity and type of infection, as stated by the Infectious Diseases Society of America and the British Association of Dermatologists 1, 2

Diagnosis of Folliculitis

• Culture is a diagnostic method to identify specific bacterial or fungal pathogens, as stated by the Infectious Diseases Society of America and the British Association of Dermatologists 1, 2
• Wood's lamp examination may show fluorescence in certain fungal infections, according to the British Association of Dermatologists 2
• Dermoscopy can help visualize characteristic features like black dot hair stubs or comma-shaped hairs, as stated by the British Association of Dermatologists 2

Prevention of Folliculitis

• Gentle skin care with pH5 neutral soaps and shampoos, tepid water, and patting skin dry is recommended to prevent folliculitis, as suggested by the American Academy of Dermatology 3
• Avoiding greasy creams and wearing fine cotton clothes instead of synthetic materials can help prevent folliculitis due to occlusive properties, as recommended by the American Academy of Dermatology 3
• Consider chlorhexidine washes or antibacterial soaps to prevent infections, and thoroughly launder clothing, towels, and bedding to prevent the spread of infection, as recommended by the Infectious Diseases Society of America 1
• Bleach baths (1/4-1/2 cup of bleach per full bath) can be used for prevention of recurrences, as suggested by the Infectious Diseases Society of America 4

Risk Factors for Folliculitis

• Poor personal hygiene is a risk factor for developing folliculitis, as stated by the Infectious Diseases Society of America 1
• Diabetes, especially for carbuncles on the back of the neck, is a risk factor for folliculitis, according to the Infectious Diseases Society of America 1
• Close personal contact with infected individuals can spread folliculitis, as stated by the Infectious Diseases Society of America 1
• Nasal carriage of S. aureus, present in 20-40% of the general population, is a risk factor for folliculitis, according to the Infectious Diseases Society of America 1

Treatment of Folliculitis

• The Infectious Diseases Society of America recommends first-line treatment with dicloxacillin, cephalexin, clindamycin, or erythromycin for folliculitis, unless there is concern for MRSA in the community 1, 4
• Topical clindamycin 1% solution/gel twice daily for 2-3 weeks is recommended as a first-line treatment for mild beard folliculitis, as suggested by the American Academy of Dermatology 5
• A 5-day course of antibiotics is as effective as a 10-day course if clinical improvement occurs, according to the Clinical Infectious Diseases guidelines and the Infectious Diseases Society of America 1, 4
• For more severe or recurrent cases, treatment may need to be extended to 2-3 weeks 4
• Oral antibiotics such as tetracycline 500 mg twice daily for up to 4 months may be used for moderate to severe cases, as suggested by the American Academy of Dermatology 5
• Clindamycin 300 mg twice daily with rifampicin 600 mg once daily for 10 weeks may be considered for extensive disease or treatment failures 5
• For suspected MRSA cases, treatment options include Trimethoprim-sulfamethoxazole (SMX-TMP) 1-2 DS tablets twice daily, Doxycycline 100 mg twice daily, Clindamycin 300-450 mg three times daily, or vancomycin, linezolid, or daptomycin for severe cases 4
• Elevation of the affected area to promote drainage of edema is recommended 1
• Prophylactic antibiotics, such as oral penicillin or erythromycin, for 4-52 weeks, or intramuscular benzathine penicillin every 2-4 weeks, may be used to prevent recurrent folliculitis, as suggested by the Infectious Diseases Society of America and the American Academy of Dermatology 4

Hormonal Treatment of Folliculitis

• The American Academy of Dermatology recommends hormonal therapy with spironolactone (100-150 mg daily) as first-line treatment for folliculitis that occurs around the menstrual cycle due to its high efficacy in managing hormonally-influenced folliculitis 6
• Spironolactone has shown an 85% improvement rate in women with hormonally-influenced follicular disorders 6
• Complete remission is achieved in 55% of patients with spironolactone treatment 6
• Combined Oral Contraceptives containing ethinyl estradiol with anti-androgenic progestins are recommended, while progestogen-only regimens should be avoided as they may worsen symptoms 6
• Metformin (500 mg 2-3 times daily) is particularly effective in women with polycystic ovarian syndrome features 6
• Finasteride (1.25-5 mg daily) can be used as adjunctive or monotherapy 6

Referral and Follow-up

• Patients with extensive or severe disease, recurrent episodes, development of scarring, or immunocompromised patients should be referred to a dermatologist for proper management 7, 8, 3
• Reassess after 2 weeks of treatment, and escalate to the next level of treatment or refer to a dermatologist if no improvement or worsening occurs 9, 3
• Laser therapy can provide long-term resolution by targeting the hair follicle, and may be the most definitive treatment option for patients with chronic or severe PFB 9, 3