Folliculitis

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Folliculitis

Maricarr Pamela M. Lacuesta and Robert G. Phelps

Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Folliculitis is inflammation of the pilosebaceous follicle. Inflammation limited to the superficial portion of the follicle clinically presents with erythematous papules and pustules, while deeper involvement manifests with furuncles and abscesses. Etiologic factors include both infectious and non-infectious agents.

Bacterial pathogens are the predominant causes of infectious folliculitis. These include Gram-positive Staphylococcus aureus, Micrococcus, Streptococcus pyogenes and Clostridium perfringens, Gram-negative Pseudomonas, Klebsiella, Proteus, Enterobacter and Citrobacter spp., Acinetobacter baumannii and Aeromonas hydrophila, Treponema pallidum and mycobacteria. Herpes and molluscum cause viral folliculitis while Candida spp., Pityrosporum spp., Rhodotorula spp., Trichosporon cutaneum and dermatophytes cause fungal folliculitis. Parasitic folliculitis may be due to Demodex spp., scabies or larva migrans. Definitive diagnosis is achieved by identification of the infectious agent/s; however, thorough history taking and detailed physical examination may provide helpful clues to the diagnosis. For example, atopic patients are particularly susceptible to staphylococcal folliculitis; a lamellar circle of desquamation surrounding the papules or pustules is a valuable clinical finding.

There should be a high index of suspicion for Gram-negative folliculitis in acne patients treated with long term antibiotics. Exposure to contaminated water in pools or jacuzzis can lead to folliculitis by Pseudomonas aeruginosa or Aeromonas hydrophila. Candida folliculitis is a frequent finding in individuals with heroin addiction and one form may preferentially affect the male beard area. Pityrosporum folliculitis, favoring the upper trunk, is more commonly found in regions with hot and humid climate and has recently been reported in a Crohn disease patient treated with infliximab. Demodex folliculitis is suggested by rosacea-like lesions on the face with periorificial accentuation. This is common among young pubescent patients but may also be associated with HIV infection or leukemia. Immunocompromised patients, most notably with HIV infection, develop not only widespread folliculocentric lesions caused by bacteria, viruses or parasites but also a characteristic sterile eosinophilic pustular folliculitis which is paradoxically related to both immune suppression and reconstitution. The clinician should utilize laboratory examinations that aid in the isolation of the infectious agents.

Non-infectious folliculitis may be associated with mechanical factors (friction, occlusion or follicular trauma), of which epilation is an example. Folliculitis has also been reported to develop over the recipient area after hair transplantation. Coal tar and cutting oils cause irritant folliculitis while sun exposure causes actinic folliculitis. Other associations include rheumatologic disorders (Behçet disease, Reiter syndrome, systemic lupus erythematosus, mixed connective tissue disease, and rheumatoid arthritis), inflammatory bowel disease, blood dyscrasias, and pregnancy. Perforating folliculitis is not only associated with diabetes mellitus and renal failure but also with TNF-α inhibitors (infliximab). The etiopathogenic mechanism for necrotizing infundibular crystalline folliculitis (waxy papules with folliculocentric filamentous birefringent crystalline deposits) is hypothesized to be physical/chemical injury or yeast and bacterial action.

Agents responsible for drug-induced folliculitis include epidermal growth factor receptor (EGFR) inhibitors, TNF-α inhibitors, trastuzumab, sorafenib, lapatinib, lenalidomide, lithium, halogens, anti-tuberculous medications, and corticosteroids.

Management strategy

Infectious folliculitis is best managed with an optimally directed antimicrobial regimen. Therapeutic options include antiseptics, topical or systemic antibiotics. Early coverage for MRSA in high risk population and areas should be considered with the emergence of community-acquired MRSA infections manifesting as folliculitis or abscess.

Eosinophilic folliculitis may resolve with topical agents. EGFR inhibitor-induced folliculitis responds well to tetracyclines. Folliculitis caused by tar and oils improves with discontinuation of exposure, although the improvement may be delayed for weeks to months.

Intramuscular immunoglobulin and photodynamic therapy have been suggested as novel treatment options for refractory folliculitis.

Specific investigations

Complete clinical investigation: thorough drug/medication history, concurrent diseases, occupational and recreational exposures, sun exposure; family history

Gram stain and mycology from touch prep, Tzanck smear or scraping; or biopsy if necessary with bacterial and fungal stains

Bacterial, fungal or viral culture methods with sensitivity testing

Complete blood count, immunologic work-up (for immunodeficiency), routine blood chemistries, renal function test, HIV status

Nasal culture if carrier state is suspected

First-line therapies

Topical therapy
Fusidic acid or mupirocin for Staphylococcus aureus	A
Retapamulin for Staphylococcus aureus	B
Mupirocin for eradication of S. aureus colonization of the nares; tea tree oil soap or body wash for body	B
Povidone-iodine, acetic acid or gentamicin for P. aeruginosa	A
Permethrin cream for Demodex spp.	D
Metronidazole cream or gel for Demodex spp.	D
Corticosteroid for eosinophilic pustular folliculitis	C
Tacrolimus for eosinophilic pustular folliculitis	D
Oral therapy
Co-trimoxazole, clindamycin, doxycycline, fusidic acid for Staphylococcus spp.	B
Ciprofloxacin for Pseudomonas folliculitis	C
Itraconazole for Pityrosporum spp.	C
Ivermectin or metronidazole for Demodex spp.	D
Indometacin or cyclosporine for eosinophilic pustular folliculitis	B
Tetracycline for EGFR inhibitor-induced folliculitis	B

Topical therapy

Topical retapamulin ointment, 1%, versus sodium fusidate ointment, 2%, for impetigo: a randomized, observer-blinded, noninferiority study.

Oranje AP, Chosidow O, Sacchidanand S, Todd G, Singh K, Scangarella N, et al. Dermatology 2007; 215: 331–40.

Retapamulin was equally efficacious with sodium fusidate in the topical treatment of superficial skin infections.

A randomized, controlled trial of tea tree topical preparations versus a standard topical regimen for the clearance of MRSA colonization.

Dryden MS, Dailly S, Crouch M. J Hosp Infect 2004; 56: 283–6.

Mupirocin was superior to tea tree regimen for clearing of nasal carriage while tea tree regimen worked slightly better than chlorhexidine or silver sulfadiazine on the body.

Refractory Demodex folliculitis in five children with acute lymphoblastic leukemia.

Herron M, O’Reilly M, Vanderhooft S. Pediatr Dermatol 2005; 22: 407–11.

Four of the five children treated with metronidazole cream for several months showed gradual improvement of folliculitis.

Recalcitrant papulopustular rosacea in an immunocompetent patient responding to combination therapy with oral ivermectin and topical permethrin.

Kallen KJ, Davis CL, Billings SD, Mousdicas N. Cutis 2007; 80: 149–51.

Resolution of the folliculitis was noted with treatment combination of 5% permethrin and ivermectin.

Successful treatment of eosinophilic pustular folliculitis with topical tacrolimus 0.1% ointment.

Ng SS, Tay YK. Dermatol Online J 2012; 18: 10.

Folliculitis in a patient showed improvement with twice daily application of 0.1% tacrolimus ointment for 2 weeks. Complete resolution occurred after 1 month.

Systemic therapy

Treatment of MRSA soft tissue infections: an overview.

Morgan M. Injury 2011; 42: S11–17.

Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa.

Yu Y, Cheng AS, Wang L, Dunne WM, Bayliss SJ. J Am Acad Dermatol 2007; 57: 596–600.

Ciprofloxacin was shown to be effective in the resolution of the acute manifestations of this syndrome.

Skin diseases associated with Malassezia species.

Gupta AK, Batra R, Bluhm R, Boekhout T, Dawson TL. J Am Acad Dermatol 2004; 51: 785–98.

Oral itraconazole was effective for extensive Pityrosporum folliculitis.

Therapeutic effectiveness of various treatments for eosinophilic pustular folliculitis.

Fukamachi S, Kabashima K, Sugita K, Kobayashi M, Tokura Y. Acta Derm Venereol 2009; 89: 155–9.

Oral cyclosporine was highly effective, as was indometacin, in alleviating the folliculitis of 11 patients.

Folliculitis induced by EGFR inhibitors, preventive and curative efficacy of tetracyclines in the management and incidence rates according to the type of EGFR inhibitor administered: a systematic literature review.

Bachet J-P, Peuvrel L, Bachmeyer C, Reguiai Z, Gourraud PA, Bouché O, et al. Oncologist 2012; 17: 555–68.

A tetracycline (doxycycline 200 mg/day) should be prophylactically prescribed together with the EGFR inhibitor to prevent folliculitis. The criterion deemed as best end-point for assessment of the efficacy of preventive treatment for EGFR inhibitor folliculitis was improvement in grading of folliculitis during the fourth or sixth week of treatment.

Second-line therapies

Oral antimicrobials
Tigecycline and vancomycin for MRSA	A
Other treatment modalities
Intramuscular immune globulin	B
Photodynamic therapy	D
Ketoconazole for Pityrosporum spp.	D

Efficacy and safety of tigecycline compared with vancomycin or linezolid for treatment of serious infections with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococci: a phase III, multicenter, double-blind, randomized study.

Florescu I, Beuran M, Dimov R, Razbadauskas A, Bochan M, Fichev G, et al. J Antimicrob Chemother 2008; 62: i17–28.

Tigecycline and vancomycin showed similar clinical cure rates in patients with skin and skin structure infections caused by MRSA.

Intramuscular immunoglobulin for recalcitrant suppurative diseases of the skin: a retrospective review of 63 cases.

Goo B, Chung HJ, Chung WG, Chung KY. Br J Dermatol 2007; 157: 563–8.

Intramuscular human immunoglobulin injections reduced the severity and the appearance of new lesions in patients with intractable suppurative skin diseases including folliculitis, with minimal adverse reactions.

Topical methyl aminolevulinate photodynamic therapy for the treatment of folliculitis.

Horn M, Wolf P. Photodermatol Photoimmunol Photomed 2007; 23: 145–7.

Seven patients with recalcitrant folliculitis were treated with methyl aminolevulinate photodynamic therapy. A single treatment session led to reduction in inflammatory lesions in six of seven patients.

Malassezia folliculitis: characteristics and therapeutic response in 26 patients.

Lévy A, Feuilhade de Chauvin M, Dubertret L, Morel P, Flageul B. Ann Dermatol Venereol 2007; 134: 823–8.

Combination topical and systemic ketoconazole cleared 75% of patients with Pityrosporum folliculitis.

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Folliculitis

Folliculitis

Management strategy

Specific investigations

First-line therapies

Topical therapy

Topical retapamulin ointment, 1%, versus sodium fusidate ointment, 2%, for impetigo: a randomized, observer-blinded, noninferiority study.

A randomized, controlled trial of tea tree topical preparations versus a standard topical regimen for the clearance of MRSA colonization.

Refractory Demodex folliculitis in five children with acute lymphoblastic leukemia.

Recalcitrant papulopustular rosacea in an immunocompetent patient responding to combination therapy with oral ivermectin and topical permethrin.

Successful treatment of eosinophilic pustular folliculitis with topical tacrolimus 0.1% ointment.

Systemic therapy

Treatment of MRSA soft tissue infections: an overview.

Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa.

Skin diseases associated with Malassezia species.

Therapeutic effectiveness of various treatments for eosinophilic pustular folliculitis.

Folliculitis induced by EGFR inhibitors, preventive and curative efficacy of tetracyclines in the management and incidence rates according to the type of EGFR inhibitor administered: a systematic literature review.

Second-line therapies

Efficacy and safety of tigecycline compared with vancomycin or linezolid for treatment of serious infections with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococci: a phase III, multicenter, double-blind, randomized study.

Intramuscular immunoglobulin for recalcitrant suppurative diseases of the skin: a retrospective review of 63 cases.

Topical methyl aminolevulinate photodynamic therapy for the treatment of folliculitis.

Malassezia folliculitis: characteristics and therapeutic response in 26 patients.

Recent Posts

Categories

Search Engine

Folliculitis

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