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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Organ System>
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Folliculitis

Spyridon Marinopoulos, M.D.
04-16-2009

  • Information below applies to Zambia, though some treatment modalities may not be available.
Zambia Information Author: Spyridon Marinopoulos, M.D.

PATHOGENS

  • Staphylococcus aureus (most common in HIV and non-HIV-related folliculitis)
  • Pityrosporum ovale (aka Malassezia furfur)
  • Demodex folliculorum
  • None: eosinophilic folliculitis
  • HSV  
  • Micrococcus
  • Pseudomonas
  • Trichophyton
  • Gram negative rods (Klebsiella, Enterobacter, Proteus)
  • Community-acquired methicillin-resistance Staph. aureus (CA-MRSA)

CLINICAL

  • Eosinophilic folliculitis: More common in advanced HIV w/ CD4 typically <250. Hx: severe pruritus w/ lesions over face, neck, upper trunk, upper arms. Spares palms, soles & digital web spaces. Chronic, waxing/waning course. PE: multiple erythematous & edematous (urticarial) papules of follicular distribution w/ a few lesions topped by pustules or crusts. Usually affects upper trunk but also face (esp. forehead), neck & upper arms. Scratching causes excoriated papules, crusts, bleeding, scarring & (in dark-skinned pts) secondary hyperpigmentation. Repeated trauma induces development of prurigo nodularis.
  • Papular urticaria: Pruritic, skin-colored or erythematous, non-follicular papules. Similar in appearance to insect bites and in distribution to eosinophilic folliculitis. Histology: nonspecific.
  • Pityrosporum (Malassezia) folliculitis: Multiple small, monomorphic follicular-centered papules & pustules affecting upper trunk, arms, occ face. Very pruritic. Histology: pityrosporum spores within follicular lumen.
  • Demodex folliculitis: Papular eruption on head, neck, trunk & arms. Histology: presence of mites.
  • Staphylococcal folliculitis: Isolated, follicular-centered pustules. Eventual formation of bullae/honey-colored crusts w/erythema, edema & exudate. Most common type in HIV+ pts. Consider CA-MRSA if periumbilical folliculitis or superficial folliculitis arising in areas not typically affected by MSSA, such as the chest, flanks, and scrotum.
  • HSV folliculitis: vesiculopustular eruption often from autoinoculation after shaving through HSV lesion on lip/mouth. Usually affects face/beard area. HIV+ pts may present w/ necrotizing folliculitis manifesting as 0.2-1.0 cm papules w/ firm central crusts. Bx may be required for Dx.
  • Pseudomonas ("hot tub") folliculitis: multiple pruritic, round, edematous/erythematous lesions w/ central papule/pustule. Acquired from hot tubs, whirlpools, heated swimming pools contaminated w/ Pseudomonas. Lesions appear on trunk +/- extremities 6-72 h post exposure & resolve spontaneously in 7-10 d. Gram negative (non-Pseudomonas) folliculitis: most often presents as sudden exacerbation in pts on long-term ABx for acne as a result of Gram (-) bacterial overgrowth.

DIAGNOSIS

  • Skin Bx w/ special stains for fungi & bacteria as well as Gram stain & KOH prep of pustule contents should be performed whenever possible.
  • Eosinophilic folliculitis: elevated serum IgE. Peripheral eosinophilia (25-50% of pts). CD4 <250. Skin Bx: follicular spongiosis with infiltration and destruction of follicular wall by eosinophils, folliculocentric inflammation. Micro: bacteria, yeasts or mites are usually not seen
  • Other: skin scraping to r/o scabies (Sarcoptes scabiei). Gram stain & Cx to r/o bacterial folliculitis. KOH stain to r/o fungal or Pityrosporum folliculitis.Tzanck smear & viral Cx to r/o HSV.

TREATMENT

TOPICAL

  • Eosinophilic folliculitis: Topical corticosteroids - usually mid-to-high potency, i.e. fluocinonide 0.05% or betamethasone 0.1%. May decrease inflammation and temporize Sx. On face/sensitive body sites, start w/ lower potency, i.e. hydrocortisone 1%, and escalate PRN.
  • Alternative: 5% permethrin cream, apply to affected area qhs x 7 d or until decreased pruritus/lesions, then 1-2x/wk.
  • Demodex folliculitis: 5% permethrin cream, apply to affected area qhs x 7d. Alternative: metronidazole 0.75-1% lotion, cream, gel qhs x 4-8 wk.
  • Pityrosporum (Malassezia) folliculitis: 2% ketoconazole cream or shampoo, apply to affected area twice-daily.
  • Staphylococcal folliculitis: chlorhexidine gluconate (Hibiclens) washes + topical 2% mupirocin to affected areas. If recurrent, eliminate nasal carriage: mupirocin 2% to nares twice-daily x 5-7 d. May repeat q3mos if no resolution. Family members may be nasal carriers; consider Rx'ing.
  • Gram negative folliculitis: (1) Pseudomonas folliculitis: Acetic acid 5% compresses x 20 min 2-4 times daily effective for Sx relief. (2) Gram negative (non-Pseudomonas) folliculitis: D/C PO ABx (tetracycline, minocycline etc.) for acne & use benzoyl peroxide wash twice-daily + systemic regimen.
  • All cases: Topical antipruritic medications such as menthol-containing lotions, pramoxine, or doxepin 5% cream may help control pruritus.
SYSTEMIC

  • Eosinophilic folliculitis: HAART may result in improvement by restoring immune function, but may also cause flare-up during the immune reconstitution period
  • Cetirizine 20-40 mg PO once-daily in divided doses (preferred, has anti-eosinophil effect) or hydroxyzine 25-50 mg PO qhs.
  • Metronidazole 250 mg PO 3 times daily x 3-4 wk completely cleared lesions in one small study
  • Itraconazole 200 mg PO once-daily x 4 wk; if no/inadequate response, retreat w/ itraconazole 300-400 mg once-daily x 4 wk.
  • Severe disease: isotretinoin 0.5 mg/kg PO twice-daily x 4-6 wks.
  • Severe, acute disease: prednisone (>0.5 mg/kg/d) as short course may be used to induce rapid remission. Relatively contraindicated in immunocompromised population, use as last resort.
  • Pityrosporum (Malassezia) folliculitis: itraconazole 200 mg PO once-daily x 4 wks.
  • Staphylococcal folliculitis (MSSA): Dicloxacillin 500 mg PO 4 times daily x 7-10 d. PCN allergy: clindamycin 300 mg PO 3 times daily x 7-10 d or doxycycline 100 mg PO twice-daily x 14 d or azithromycin 500 mg, then 250 mg once-daily x 4d or clarithromycin 500 mg PO twice-daily x 7-10 d. Staphylococcal folliculitis (CA-MRSA): TMP/SMX DS PO twice-daily x 7-10d or clindamycin 300 mg PO 3 times daily x 7-10 d or doxycycline 100 mg PO twice-daily x 14 d or minocycline 100 mg PO twice-daily x 14 d (If abscess present, culture pus and modify treatment based on sensitivities).
  • HSV folliculitis: acyclovir 400 mg PO 3 times daily or valacyclovir 500 mg PO twice-daily or famciclovir 125 mg PO twice-daily x 5 d.
  • Gram negative folliculitis: 1) Pseudomonas folliculitis: Not first line, use only if persistent/immunosuppressed - ciprofloxacin 500 or 750 mg PO twice-daily x 7-10 d. 2) Gram negative (non-Pseudomonas) folliculitis: isotretinoin 0.5-1.0 mg/kg PO twice-daily x 4-6 mos effective. Alternative: PO ABx based on C&S of predominant organisms, usually TMP/SMX DS PO twice-daily or amox/clav 250-500 mg PO 3 times daily.
PHOTOTHERAPY

  • Eosinophilic folliculitis: UVB or PUVA (psoralen + ultraviolet A) x 3-6 wks. Generally effective.

Drug Comments

DrugRecommendations/Comments
Itraconazole Used to Rx eosinophilic folliculitis. Inhibits cytochrome P450-dependent synthesis of ergosterol. Disulfiram-like reaction w/ EtOH. Significant drug-drug interactions. Antacids may reduce absorption. Rhabdomyolysis potential w/ statins. Increases plasma levels of benzos (esp. midazolam and triazolam). Potential for hepatotoxicity.
Metronidazole Used to Rx eosinophilic folliculitis. Disulfiram reaction w/ EtOH. Interaction w/ anticoagulants, lithium, phenytoin; cimetidine may increase toxicity.
Mupirocin Used to treat Staph, including MRSA, beta-hemolytic strep and Strep. pyogenes. Prolonged use may result in overgrowth of nonsusceptible organisms and methicillin resistance.
Permethrin No documented cases of resistant scabies.Treatment may temporarily exacerbate itching, redness, and swelling; do not use near eyes or in mucous membranes

OTHER INFORMATION

  • Recommendations are author's opinion. Dx superficial folliculitis in pt w/ small (1-2 mm) erythematous papules/pustules at openings of hair follicles. Not assoc w/ systemic Sx & heals without scarring. Dx deep folliculitis in pt w/ red, swollen, tender, nodular/pustular follicle-centered masses. Involves entire hair follicle & appears as red, swollen nodules/pustules deeper & larger than in superficial folliculitis.
  • DDx: eosinophilic folliculitis, infectious folliculitis (fungal - Pityrosporum/Trichophyton, bacterial - Staph/Pseudomonas/other Gram neg, parasitic - Demodex, viral - HSV), papular urticaria, acne, keratosis pilaris, drug eruption, scabies, insect bites, follicular eczema, pustular psoriasis, subcorneal pustular dermatosis (Sneddon-Wilkinson).
  • Predisposing factors: friction, perspiration, occlusion (clothing, adhesives), shaving, depilatories, preexisting dermatitis, reduced host resistance (DM, hypogammaglobulinemia, chronic granulomatous disease, meds - systemic corticosteroids or cytotoxic agents), Staph nasal carriage, skin injuries/wounds/abscess, exposure to precipitants (mineral oils, tars, cutting oils, paraffin-based oint).
  • May safely treat folliculitis w/ topical corticosteroids & cetirizine while awaiting Bx or Cx results. If results positive, treat specific etiology.
  • In bacterial (Staph) folliculitis, local skin care & topical ABx can be used first-line esp. if infection superficial; if area involved widespread or deep infection present, use PO ABx. Drug of choice must cover PCN-resistant S. aureus. For fungal folliculitis, broad-spectrum topical antifungals may be used first-line in superficial cases, w/ PO antifungals reserved for persistent/deep infection.

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