Updated: 7/6/2020

Folliculitis

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Snapshot
  • A 25-year-old woman presents to her dermatologist reporting a new itchy skin rash. She reports going to a pool party recently, where she shared a hot tub with 10 other people. On her thighs and abdomen are clusters of small pustules and papules overlying an erythematous base. She is prescribed daily acetic acid baths and topical benzoyl peroxide. (Hot tub folliculitis)
Introduction
  • Clinical definition
    • superficial inflammation of the hair follicles characterized by perifollicular papules and pustules
  • Epidemiology
    • demographics
      • more common in men
      • 20-40 years of age
    • risk factors
      • prolonged use of antibiotics
      • topical corticosteroids
      • pin worms (especially folliculitis on the buttocks)
      • exposure to hot tubs, pools, or baths containing contaminated water
        • “hot tub folliculitis” caused by Pseudomonas aeruginosa
        • immunodeficiency
  • Etiology
    • bacterial
      • Pseudomonas aeruginosa
      • Staphylococcus aureus
    • fungal
      • Malassezia spp.
      • Candida spp.
      • Tinea spp.
        • more common in children
    • viral
      • herpes virus
    • parasites
      • Demodex spp.
  • Associated conditions
    • acne
    • neutropenia
    • atopic dermatitis
    • diabetes
  • Prognosis
    • waxing and waning nature
    • can progress into furuncle or carbuncle
      • furuncle
        • infection of hair follicules and associated with abscess
      • carbuncle
        • a collection of furuncles that drain through follicular orifices
Presentation
  • Symptoms
    • clusters of pustules that wax and wane
    • often pruritic
  • Physical exam
    • single or clusters of small pustules or papules surrounding a hair follicle on an erythematous base
    • occurs on hair-bearing skin
      • staphylococcal often occurs on face, buttocks, legs, and axilla
      • pseudomonal often occurs on trunk
      • candida often occurs in skin folds
Studies
  • Microbiology testing for bacteria, fungus, and virus
    • indications
      • if disease is refractory to standard therapy or are unusually severe
Differential
  • Pseudofolliculitis barbae
  • Acne vulgaris
  • Keratosis pillaris 
    • key distinguishing factors
      • autosomal dominant
      • rough papules on the skin with hard plugs
Treatment
  • Conservative
    • daily acetic acid bath
      • indication
        • for gram-negative bacteria as this usually resolves without treatment
  • Medical
    • topical mupirocin 
      • indication
        • first-line
    • topical benzoyl peroxide
      • indication
        • first-line
    • systemic antibiotics, anti-fungals, or anti-virals
      • indication
        • if therapy is refractory to first-line therapy
Complications
  • Deeper infection
    • such as furuncle or carbuncle
  • Alopecia
    • if hair follicle is damaged

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