Folliculitis

Definition

 

  • Infection of hair follicle
  • Types:
    • Superficial Pustular Folliculitis:
      • Aka follicular impetigo or Bockhart impetigo
      • Site; Face, Perioral
    • Folliculitis barbae:
      • Commonly in 20-40 years of age
      • Sycosis barbae: Most severe type of this kind
      • +/- Marginal Belpharitis and conjunctivitis
    • Perifolliculitis capitis:
      • Fluctuating
      • Interconnecting nodules
      • Susceptible to 2nd bacterial/Fungal infection
    • Folliculitis keloidalis nuchae, aka acne keloidalis
    • Actinic folliculitis:
      • 24 hrs after exposing to sunlight
    • Malassezia folliculitis:
      • Small
      • Scattered
      • Itchy
      • Follicular papules
      • Mostly on the back, chest, posterior arms and +/- neck
      • Slowl growth and finally becomes pustular
    • Epidermal Growth Factor Receptor (EGFR inhibitors) induced folliculitis
      • Eg: Gefitinib, Cetuximab
      • 1-3 weeks after administering the medication

Epidemiology

  • Chronic Cellulitis
    • Mostly between 16- 25 y
  • African Descent
  • Gender: Men more severe on Average
  • Prevalence: 45%-83% among African populations

DDx

  • Tinea Corporis infection:
  • Pustular Miliaria

Causes

  • Idiopathic
  • Ingrowth hair under skin
  • Fungal
  • Bacterial:
    • Staph aureus (Most Common)
    • Pseudomonas aeruginosa (In hot tubs)
  • Skin friction
  • Parasitic
  • Viral
    • HIV => Eosinophilic folliculitis

Risk Factors

  • Adipose gland adjacent to hair follicle occlusion
  • Ingrowth hair under skin
  • Shaving
  • Cutaneous abscess drainage
  • Surgical wound drainage
  • Plastic/plaster dressing
  • Sun Exposure

Complications

  • Usually no scaring
  • Furuncles or carbuncles
  • Abscess
  • Painful cysts requiring surgical drainage

Presenting symptoms

  • Most common sites:
    • Head
    • Neck
    • Buttock
    • Trunk
  • Tender in Palpation
  • Pruritus
  • Superficial pustule
  • Inflammatory nodule
  • Hair follicle is seen mostly at the centre of the inflammation
  • Superficial Pustular Folliculitis:
    • Site; Face, Perioral
  • Folliculitis barbae:
    • +/- Marginal Belpharitis and conjunctivitis
  • Perifolliculitis capitis:
    • Fluctuating
    • Interconnecting nodules
    • Susceptible to 2nd bacterial/Fungal infection
  • Actinic folliculitis:
    • 24 hrs after exposing to sunlight
  • Malassezia folliculitis:
    • Small
    • Scattered
    • Itchy
    • Follicular papules
    • Mostly on the back, chest, posterior arms and +/- neck
    • Slow growth and finally becomes pustular
  • Epidermal Growth Factor Receptor (EGFR inhibitors) induced folliculitis
    • Eg: Gefitinib, Cetuximab
    • 1-3 weeks after administering the medication

Signs

  • Pain
  • Itching

Red flags

  • Swollen
  • Painful
  • Sever tenderness
  • Fever
  • Sub-cutaneous abscess
  • Immuno-compromised patients
  • HIV +Ve Patients

 

Lab work ups

  • Diagnosis is mainly through P/E
  • If suspicious to Eosinophilic Folliculitis, R/O Immunosuppression:
    • HIV ELISA
    • CBC with diff
  • If suspicious to Fungal cause:
    • KOH smear preparation

Diagnostics

  • No imaging required
  • Diagnosis is mainly through P/E and also Hx

Management

  • Eliminate underlying cause:
    • Remove plaster
    • Replace/ remove the plastic dressing
  • Mupirocin topical ointment
  • Aluminum Acetate 1/20 or 1/40 solution
    • Soak 6 layers of gauze in the solution
    • Change dressing q 2-3 hrs
  • Antibiotics:
    • Dicloxacillin: 250-500 mg PO q6h X 10 days
    • Erythromycin: 250-500 mg PO q6hX 10 days
  • Topical steroid creams:
    • Indication: Severe inflammation
  • If eosinophilic folliculitis:
    • Itraconazole: 100-400 mg po qd
    • Anti Retroviral Therapy (ART)
    • Isotertinoin: 40-80 mg/day, 0.5–1.2 mg/kg per day)
    • UVB Phototherapy
    • Permethrine 5% topical cream
    • Topical antihistamines and Corticosteroids

References

  • Guidelines on the Treatment of Skin and Oral HIV-Associated Conditions in Children and Adults. Geneva: World Health Organization; 2014. 7, Evidence and recommendations on eosinophilic folliculitis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK305422/
  • Sun, K. L., & Chang, J. M. (2017). Special types of folliculitis which should be differentiated from acne. Dermato-endocrinology, 9(1), e1356519. doi:10.1080/19381980.2017.1356519
  • Luelmo-Aguilar J, Santandreu MS. Folliculitis: recognition and management. Am J Clin Dermatol. 2004;5(5):301-10. Review. PubMed PMID: 15554731.
  • Laureano AC, Schwartz RA, Cohen PJ. Facial bacterial infections: folliculitis. Clin Dermatol. 2014 Nov-Dec;32(6):711-4. doi: 10.1016/j.clindermatol.2014.02.009. Epub 2014 Mar 1. Review. PubMed PMID: 25441463.
  • Prasad P, Anandhi V, Jaya M. Chronic folliculitis – A clinico-epidemiological Indian J Dermatol Venereol Leprol. 1997 Sep-Oct;63(5):304-6. PubMed PMID:  20944361.

 

 

 

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