Definition
A.Inflammation of the superficial or deep portion of the hair follicle. Folliculitis is a bacterial infection of the hair follicle.
Incidence
A.A very common disorder, folliculitis occurs in all ages and is seen more frequently in males.
Pathogenesis
A.Bacterial organisms (most common Staphylococcus aureus) invade the follicle wall and cause an infectious process.
Predisposing Factors
A.Break in the skin tissue.
B.Use of razors on skin.
C.Poor hygiene.
D.Diabetes.
E.Long-term oral antibiotic therapy for acne.
F.Exposure to hot tubs or heated swimming pools.
Common Complaints
Outbreak of pustules on the face, scalp, or extremities that do not resolve despite proper hygiene and care.
Other Signs and Symptoms
A.Tenderness and itching at site.
B.Furuncle (abscess): A deep pustule, tender, firm or fluctuant, found in groin, axilla, waistline, buttocks.
C.Carbuncle: A group of follicles coalescing into one larger, painful, infected area; may see fever and chills.
D.Excoriated folliculitis: Chronic thickened, excoriated papules or nodules.
Subjective Data
A.Elicit the initial outbreak of lesions and onset and progression of lesions.
B.Identify what makes the lesions better or worse.
C.Ask the patient what medications, soaps, or lotions have been used on the lesions.
D.Complete a medical history. Ask if the patient has had an outbreak similar to this before.
E.Describe systemic symptoms if they have occurred (fever, chills, etc.).
F.Does the patient have a beard, shave his face, or use a razor frequently?
G.Is there a recent history of use of a hot tub? (Commonly seen 1 to 4 days after use of hot tub, whirlpool, or swimming pool.)
H.Does the patient wear tight pants/jeans or use oils that clog pores in the groin area?
I.Is the patient currently being treated with antibiotics for acne? (May see flare of gram-negative folliculitis with chronic use of antibiotics.)
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect: Assess skin for lesions and describe.
C.Palpate: Palpate lesions and associated lymph nodes.
Diagnostic Tests
A.Culture and sensitivity to verify appropriate antibiotic coverage.
B.Gram stain.
C.Potassium hydroxide (KOH)/wet prep.
D.Fungal culture hair if fungi suspected (tinea of scalp).
Differential Diagnoses
A.Folliculitis.
B.Acne vulgaris.
C.Ingrown hair follicle.
D.Keratosis pilaris.
E.Contact dermatitis.
F.Papulopustular rosacea.
G.Hidradenitis suppurativa.
Plan
A.General interventions: Apply warm, moist compresses to site for comfort.
B.See Section III: Patient Teaching Guide Folliculitis.
1.If razors are used on the area, have the patient use clean, sharp razors; throw old razors away, and do not share razors. Avoid use of irritating creams or lotions on affected area.
2.Encourage proper hygiene, such as frequent washing of hands and skin with antibacterial soap.
3.Warm compresses three to four times a day are encouraged at site for 15 to 20 minutes.
4.Bleach bath (1/2–1 cup of bleach to 20 L water) reduces spread of staph infection.
C.Pharmaceutical therapy:
1.Mild cases: Apply mupirocin (Bactroban) ointment to affected area three times daily until resolved.
2.S. aureus:
a.Dicloxacillin (Dynapen) 250 to 500 mg by mouth four times daily for 7 to 10 days.
b.Cephalexin (Keflex) 250 to 500 mg by mouth twice daily for 7 to 10 days.
3.Methicillin-resistant Staphylococcus aureus (MRSA):
a.Trimethoprim/sulfamethoxazole one to two double strength (DS) tablets twice daily for 7 to 10 days.
b.Doxycycline 100 mg twice daily for 7 to 10 days.
4.Pseudomonas aeruginosa:
a.Ciprofloxacin (Cipro) 500 mg by mouth twice daily for 10 days.
b.Ofloxacin 400 mg by mouth twice daily for 10 days.
5.Antistaphylococcal antibiotics:
a.Cephalexin 250 to 500 mg four times a day.
b.Clindamycin 150 to 300 mg four times a day.
c.Dicloxacillin 125 to 500 mg four times a day.
d.Erythromycin 250 to 500 mg four times a day.
6.Bacteria caused by organisms other than Staphylococcus may be treated for an extended period of time, 4 to 8 weeks. These areas may include axilla, chest, back, beard, and groin.
7.Severe cases may be treated with oral antibiotics with topical permethrin every 12 hours every other night for a 6-week period or itraconazole 400 mg daily, isotretinoin 0.5 mg/kg/d for up to 4 to 5 months with UVB light therapy. Consider dermatology referral for severe cases.
Follow-Up
A.If not resolved in 2 weeks, further evaluation is needed.
B.Severe cases, in which carbuncles are not improved with treatment of antibiotic therapy, may warrant incision and drainage.
C.Continue to follow every 2 weeks until resolved.
D.Test for diabetes mellitus if severe cases occur.
Consultation/Referral
A.Refer the patient to a physician for testing for immuno deficiency if severe cases occur or if resistance is seen.
B.Dermatology referral.