Management of Folliculitis Due to Rinvoq (Upadacitinib)

Treatment Approach

For patients with folliculitis on Rinvoq, the American College of Dermatology recommends initiating topical clindamycin 1% solution or gel twice daily for at least 12 weeks as first-line therapy while continuing Rinvoq, and escalating 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
The American Academy of Dermatology suggests that doxycycline and minocycline are more effective than tetracycline, though neither is superior to the other 1, 2

For mild folliculitis, continue Rinvoq at current dose and apply topical clindamycin 1% solution/gel twice daily for 12 weeks, with alternative topical options including erythromycin 1% cream or metronidazole 0.75% 1, 3
For moderate folliculitis, escalate to oral tetracycline 500 mg twice daily for 4-12 weeks, and consider adding short-term topical corticosteroids for 2-3 weeks 1, 2, 3

The American Academy of Dermatology recommends cleansing with gentle pH-neutral soaps and tepid water, patting skin dry after showering, and wearing loose-fitting cotton clothing to prevent folliculitis 6, 1
Apply hypoallergenic moisturizing emollients once daily, but avoid greasy creams in affected areas as they facilitate folliculitis development 6, 1

For recurrent folliculitis, implement a 5-day decolonization regimen with intranasal mupirocin twice daily, daily chlorhexidine body washes, and decontamination of personal items, and consider oral clindamycin 150 mg once daily for 3 months 1, 2, 5
For refractory cases, consider combination therapy with oral clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks, and consult dermatology for chronic grade 2 or higher folliculitis 2, 3

The FDA recommends monitoring closely for signs of infection during Rinvoq treatment, and obtaining bacterial swabs if secondary infection is suspected, as Staphylococcus aureus is the most frequently detected infectious agent 6, 5
For large furuncles or abscesses, incision and drainage is the primary and most effective treatment, with thorough evacuation of pus and probe of the cavity to break up loculations 2, 5

Initial systemic antibiotic duration is 5 days, with extension if no improvement occurs, and 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, and consider alternative treatments such as erythromycin or azithromycin for pregnant women or children under 8 years who cannot take tetracyclines 2, 1