Strongest Antibiotic For Folliculitis

The condition is due to obstruction or flow disruption in pilosebaceous glands ± infection. Furuncles are a more deep-seated infection of the base of the hair follicle, characterised by inflammatory nodules and pus formation, which may result from folliculitis. They may develop into carbuncles.

Folliculitis Treatment and Management

It is essential to determine presumptive etiology based on clinical history, morphology and distribution of the lesions, along with severity before a treatment plan is devised. For uncomplicated superficial folliculitis, use of antimicrobial cleansers such as benzoyl peroxide and good hand-washing techniques may be all that is needed. Lesions which are more inflamed often respond well to warm compresses with or without the use of a topical antistaphylococcal agent. For refractory or deep lesions where an infectious etiology is suspected, empiric treatment with oral antibiotics that cover gram-positive organisms should be considered. For patients who do not improve with a standard course of antibiotics, other causes of folliculitis must be investigated.

If systemic antibiotics are indicated, coverage should include S aureus since it is the most common pathogen. Because this organism may be penicillin resistant, dicloxacillin or a cephalosporin are the initial choices of therapy. Methicillin-resistant organisms are becoming more common, and treatment may require clindamycin, trimethoprim-sulfamethoxazole, minocycline, or linezolid.

Deep folliculitis is best approached with warm compresses, followed by incision and drainage once a conical pustular head develops. For recurrent and recalcitrant folliculitis, in addition to oral antibiotics, a search for a bacterial reservoir is important. Mupirocin ointment in the nasal vestibule twice a day for 5 days may eliminate the S aureus carrier state. Family members may also be nasal carriers of S aureus, and mupirocin ointment or rifampin at 600 mg/d orally for 10 days may eliminate the carrier state.

Medical care for the other types of folliculitis is as follows:

Pseudomonas folliculitis is usually self-limited and does not require treatment; however, if the patient is immunocompromised or the lesions are persistent, oral ciprofloxacin may be given.

Eosinophilic pustular folliculitis (Ofuji disease) does not respond to systemic antibiotics. First line treatment is indomethacin (50 mg/day). Other therapies include UVB phototherapy, minocycline, or dapsone. [36] Successful second-line treatment of refractory disease with abrocitinib has been reported. [37] HIV-associated folliculiitis typically significantly improves or completely resolves with antiretroviral therapy, and occassionall topical steroids may be required for resistent cases. Second line therapy includes phototherapy with broad band ultraviolet light (UVB). [41, 42]

Pityrosporum folliculitis initially responds to topical antifungals such as ketoconazole cream or shampoo but is often associated with relapses. For relapses, systemic antifungals such as fluconazole and itraconazole should be initiated.

Candida folliculitis is usually treated with oral fluconazole; however, topical antifungal solutions or creams can be initially tried. [26]

Gram-negative folliculitis that arises as a complication of chronic antibiotic use is best approached by discontinuing the implicated antibiotic and administering oral trimethoprim-sulfamethoxazole. Use of benzoyl peroxide washes may also be beneficial.

Demodex Folliculitis is usually initially treated with topical ivermectin, permethrin, or metronidazole, but the latter is typically less effective. Alternative topical treatments include tea tree oil or baby shampoo as a facial wash, and various light therapies. Oral therapies include ivermectin and combined oral ivermectin and metronidazole [40, 51]

Herpetic folliculitis responds to valacyclovir, famciclovir, or acyclovir.

Actinic folliculitis usually spontaneous resolves with cessation of sunlight exposure, for persistent cases topical retinoids such as adapalene can be helpful, but, occassionally oral isotretinoin therapy may be required for refractory cases. [44, 45]

Papulopustular eruption associated with epidermal growth factor receptor inhibitors is self-limited and resolves with cessation of chemotherapy. In patients requiring treatment, topical antibiotics, topical corticosteroids or oral antibiotics. Oral tetracyclines represent an efficacious prophylactic option for suitable patients at the beginning treatment. [38] There is also good evidence supporting systemic retinoid therapy. [39]

Consultations

The patient’s primary care provider can usually diagnose and treat uncomplicated cases of folliculitis, but for those cases that are persistent or result in scarring, a dermatologist should be consulted.

Prevention

Avoid shaving irritated skin for 1 month or until all lesions have resolved. To prevent future lesions, avoid close shaving and change disposable razors daily. In addition, periodically soak electric razor heads in 70% alcohol or diluted bleach for 1 hour to eliminate overgrowth of bacteria or fungi. Do not share razors with other members of the household.

Good personal hygiene, including bathing, hand washing, and keeping nails short and clean, reduces the risk of folliculitis. Wearing loose rather than snug-fitting clothing helps reduce friction. If the patient equates episodes of folliculitis to wearing a wet suit or other sports gear, these items should be cleaned with antimicrobial soaps and dried well.

In cases of acute infectious folliculitis, launder towels, washcloths, and sheets frequently and do not share them with other family members.

Hot tubs should be cleaned regularly and appropriately chlorinated.

References

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18. Laureano AC, Schwartz RA, Cohen PJ. Facial bacterial infections: folliculitis. Clin Dermatol. 2014 Nov-Dec. 32 (6):711-4. [QxMD MEDLINE Link].
19. Rubenstein RM, Malerich SA. Malassezia (pityrosporum) folliculitis. J Clin Aesthet Dermatol. 2014 Mar. 7 (3):37-41. [QxMD MEDLINE Link].
20. Tsai YC, Wang JY, Wu YH, Wang YJ. Atypical clinical presentations of Malassezia folliculitis: a retrospective analysis of 94 biopsy-proven cases. Int J Dermatol. 2018 Mar. 57 (3):e19-e20. [QxMD MEDLINE Link].
21. Schuler A, Veenstra J, Tisack A. Folliculitis Induced by Laser Hair Removal: Proposed Mechanism and Treatment. J Clin Aesthet Dermatol. 2020 May. 13 (5):34-36. [QxMD MEDLINE Link].
22. Eley CD, Gan VN. Picture of the month. Folliculitis, furunculosis, and carbuncles. Arch Pediatr Adolesc Med. 1997 Jun. 151(6):625-6. [QxMD MEDLINE Link].
23. Livani F, Kabir S. Gram-negative folliculitis caused by Morganella morganii. JAAD Case Rep. 2019 Jun. 5 (6):558-559. [QxMD MEDLINE Link].
24. Lousada MB, Lachnit T, Edelkamp J, Rouillé T, Ajdic D, Uchida Y, et al. Exploring the human hair follicle microbiome. Br J Dermatol. 2020 Aug 6. [QxMD MEDLINE Link].
25. Olszewski AE, Karandikar MV, Surana NK. Aeromonas as a Cause of Purulent Folliculitis: A Case Report and Review of the Literature. J Pediatric Infect Dis Soc. 2016 Dec 16. [QxMD MEDLINE Link].
26. Okwuwa I, Alam N, Wai R, Shayeb M, Sanchez A, Gandhi K, et al. Pubic Candida Folliculitis, A Case Report in a Patient With Recurrent Vaginal Candidiasis. J Family Reprod Health. 2023 Mar. 17 (1):62-64. [QxMD MEDLINE Link]. [Full Text].
27. Dong H, Duncan LD. Cytologic findings in Demodex folliculitis: a case report and review of the literature. Diagn Cytopathol. 2006 Mar. 34(3):232-4. [QxMD MEDLINE Link].
28. Alniemi DT, Chen DL. Perioral Demodex folliculitis masquerading as perioral dermatitis in the peripartum period. JAAD Case Rep. 2019 Jul. 5 (7):639-641. [QxMD MEDLINE Link].
29. Boer A, Herder N, Winter K, Falk T. Herpes folliculitis: clinical, histopathological, and molecular pathologic observations. Br J Dermatol. 2006 Apr. 154(4):743-6. [QxMD MEDLINE Link].
30. Weinberg JM, Mysliwiec A, Turiansky GW, Redfield R, James WD. Viral folliculitis. Atypical presentations of herpes simplex, herpes zoster, and molluscum contagiosum. Arch Dermatol. 1997 Aug. 133(8):983-6. [QxMD MEDLINE Link].
31. Tilley DH, Satter EK, Kakimoto CV, Lederman ER. Disseminated verrucous varicella zoster with exclusive follicular involvement. Arch Dermatol. 2012 Mar. 148 (3):405-7. [QxMD MEDLINE Link].
32. Bensadoun RJ, Humbert P, Krutman J, Luger T, Triller R, Rougier A, et al. Daily baseline skin care in the prevention, treatment, and supportive care of skin toxicity in oncology patients: recommendations from a multinational expert panel. Cancer Manag Res. 2013. 5:401-8. [QxMD MEDLINE Link]. [Full Text].
33. Zancanaro PC, McGirt LY, Mamelak AJ, Nguyen RH, Martins CR. Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience. J Am Acad Dermatol. 2006 Apr. 54(4):581-8. [QxMD MEDLINE Link].
34. Vary JC Jr, Colven R, Kirby P. Hypertrophic scars from surgical staples mimicking folliculitis. J Am Acad Dermatol. 2010 Jan. 62(1):157-8. [QxMD MEDLINE Link].
35. Weedon D, Strutton G. Skin Pathology. 2nd ed. New York, NY: Churchill Livingstone; 2002. 459-66.
36. Satoh T, Shimura C, Miyagishi C, Yokozeki H. Indomethacin-induced reduction in CRTH2 in eosinophilic pustular folliculitis (Ofuji’s disease): a proposed mechanism of action. Acta Derm Venereol. 2010. 90(1):18-22. [QxMD MEDLINE Link].
37. Cai L, Yan Y, Li Y, Lin J, She X, Wang X. Two cases of eosinophilic pustular folliculitis successfully treated with abrocitinib. J Dermatol. 2024 May 28. [QxMD MEDLINE Link].
38. Gorji M, Joseph J, Pavlakis N, Smith SD. Prevention and management of acneiform rash associated with EGFR inhibitor therapy: A systematic review and meta-analysis. Asia Pac J Clin Oncol. 2022 Dec. 18 (6):526-539. [QxMD MEDLINE Link].
39. Bierbrier R, Lam M, Pehr K. A systematic review of oral retinoids for treatment of acneiform eruptions induced by epidermal growth factor receptor inhibitors. Dermatol Ther. 2022 May. 35 (5):e15412. [QxMD MEDLINE Link].
40. Li J, Wei E, Reisinger A, French LE, Clanner-Engelshofen BM, Reinholz M. Comparison of Different Anti-Demodex Strategies: A Systematic Review and Meta-Analysis. Dermatology. 2023. 239 (1):12-31. [QxMD MEDLINE Link].
41. Mohseni Afshar Z, Goodarzi A, Emadi SN, Miladi R, Shakoei S, Janbakhsh A, et al. A Comprehensive Review on HIV-Associated Dermatologic Manifestations: From Epidemiology to Clinical Management. Int J Microbiol. 2023. 2023:6203193. [QxMD MEDLINE Link].
42. Bobotsis R, Brathwaite S, Eshtiaghi P, Rodriguez-Bolanos F, Doiron P. HIV: Inflammatory dermatoses. Clin Dermatol. 2024 Mar-Apr. 42 (2):169-179. [QxMD MEDLINE Link].
43. Porter AP, James WD. Acute and recurrent pustulosis: consolidating uncommon cases of follicular pustulosis induced by UV light and other triggers. Int J Womens Dermatol. 2023 Oct. 9 (3):e100. [QxMD MEDLINE Link].
44. Rahman S, Powell J, Al-Ismail D. First reported cases of actinic folliculitis treated successfully with topical retinoid. Clin Exp Dermatol. 2020 Aug. 45 (6):716-718. [QxMD MEDLINE Link].
45. Yuan C, Wang B. Acneiform eruption induced by molecularly targeted agents in antineoplastic therapy: A review. J Cosmet Dermatol. 2023 Aug. 22 (8):2150-2157. [QxMD MEDLINE Link].
46. Bahbouhi I, Aboudourib M, Hocar O, Amal S. Vitamin B12 induced acneiform eruption. Heliyon. 2023 May. 9 (5):e16120. [QxMD MEDLINE Link].
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Media Gallery

A 22-month-old boy with a staphylococcal folliculitis on the buttocks. The lesions have been excoriated. Diaper occlusion may have been related to onset of the rash.

A 30-year-old woman with hot tub folliculitis. She had used a hot tub 2 days prior, wearing a bikini-style bathing suit.

Folliculitis

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Folliculitis article more useful, or one of our other health articles.

In this article :

Folliculitis is inflammation of the hair follicles.

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How common is folliculitis? (Epidemiology)

Prevalence

It is undoubtedly a relatively common condition in primary care. There are no reliable figures for community prevalence. It occurs in both sexes and all races. Superficial Staphylococcus aureus folliculitis is more common in children, whilst folliculitis of the beard area is more common in adult males. 1

Folliculitis causes (aetiology) 2

It can be caused by:

• Bacterial infection:
  • S. aureus is the most common.
  • Pseudomonas spp. – occurring in outbreaks associated with hot tubs, paddling pools, etc. Causes intense pruritus, particularly in areas under a bathing suit (hot tub folliculitis). 34
  • Gram-negative folliculitis affects patients with a history of long-term antibiotic therapy for acne:
    • Pathogens include Klebsiella spp., Enterobacter spp. and Proteus spp. 5
    • Malassezia folliculitis (previously called pityrosporum folliculitis) causes itchy acneiform eruption on the upper back, upper arms, chest, neck, chin and face, affecting younger patients.
    • Other fungal folliculitis:
      • Due to Candida spp. and Trichophyton spp.
      • Commonly in men, as tinea barbae in the beard area.
      • May also be caused by contact with dogs/cattle/other animals.
      • Resembles bacterial infection but may have a clearly demarcated flaking edge of confluent erythema.
      • Herpetic folliculitis due to herpes simplex viruses (HSV); often in men who shave near oral cold sore lesions.
      • Varicella zoster and mollluscum contagiosum are commonly responsible for viral folliculitis.
      • Eosinophilic pustular folliculitis; sterile and intensely itchy eruption associated with HIV infection.
      • Eosinophilic folliculitis (a rare autoimmune disease, more common in Asian races).

      The condition is due to obstruction or flow disruption in pilosebaceous glands ± infection. Furuncles are a more deep-seated infection of the base of the hair follicle, characterised by inflammatory nodules and pus formation, which may result from folliculitis. They may develop into carbuncles.

      There can be a mixed picture of skin infection with co-existence of areas of folliculitis, furuncles, carbuncles and boils.

      Risk factors for folliculitis

      • Sports participation: mechanical trauma, exposure to environmental and infectious agents, and contact with the skin of other athletes. 7
      • Uncut beard.
      • Shaving ‘against the grain’.
      • Particularly thick hair.
      • Excessive friction from clothing.
      • Overly tight-fitting clothing.
      • Excessive sweating and hyperhidrosis.
      • High external humidity.
      • Pre-existing dermatitis.
      • Reduced host immunity – eg, poorly controlled diabetes, immunosuppression.
      • Nasal carriage of infecting strains of S. aureus.
      • Skin abrasion/wound/abscess.
      • Occluded skin – particularly for dermatological treatment with topical corticosteroids.

      Continue reading below

      Folliculitis symptoms

      It may occur as a relatively trivial irritation – superficial folliculitis, or as a more deep-seated process involving the lower hair follicle. Often the cause of superficial folliculitis is unclear. The most common infecting organism is S. aureus. 8

      Deep folliculitis is more clinically significant and likely to result in scarring. These often start as a rash or a set of slowly evolving red lumps on the skin, usually on hairy areas.

      • The rash may be pain-free or cause irritation and pruritus.
      • There may be a desire to scratch.
      • If mild and left alone, the rash usually resolves without scarring.
      • Patients may notice small pustules at the centre of the lesions.
      • Commonly affected areas are the axilla, beard, face, scalp, thighs and inguinal regions.

      Rash of folliculitis

      By James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons

      Signs

      • Check temperature and exclude signs of systemic toxicity.
      • The central hair shaft may not be easy to see if hair is fine and/or fair; a magnifying glass can help demonstrate its presence.
      • Erythematous papules form in a relatively regular, sometimes ‘grid-like’, pattern. Small pustules may be seen.
      • Deep folliculitis tends to cause more erythema, becoming more confluent between the lesions, with no noticeable surface pustules and intense irritation of the skin. It can cause scarring, keloid formation and hair loss.
      • Regional draining lymph nodes should be checked for adenitis, which is rare in simple or mild folliculitis. Folliculitis of the eyelash is known as a stye or hordeolum.

      Folliculitis on the lower leg

      By Da pacem Domine, CC0, via Wikimedia Commons

      Differential diagnosis 2 9

      Common differentials include:

      • Acne vulgaris.
      • Acne rosacea.
      • Keratosis pilaris.
      • Insect bites.
      • Contact dermatitis.
      • Pseuduofolliculitis barbae.
      • Lupus or lupoid rashes.
      • Milia.
      • Lupus miliaris disseminatus faciei: rare chronic inflammatory dermatosis with red-yellow-brown papules on the central face.
      • Perioral dermatitis.
      • Reactive perforating collagenosis/perforating folliculitis.
      • Alopecia mucinosa.

      Continue reading below

      Investigations 2

      None is usually needed.

      • If recurrent, send off swabs for culture from sites of staphylococcal carriage (family/fellow residents may need to be checked) and exclude diabetes mellitus.
      • If there is atypical response to therapy or episodes are recurrent, consider punch biopsy, Gram-staining of skin swabs/scrapings, scrapings for fungal culture or potassium hydroxide test.
      • Pustules can be deroofed with a scalpel and pus collected for Gram-staining and culture in severe or resistant cases.
      • If HSV folliculitis is suspected then it may be worth sending vesicopustular fluid for viral culture to confirm the diagnosis.
      • Skin biopsy shows different types of infiltrate in the walls and lumen of the hair follicle, dependent on cause.
      • Cytology is being used by dermatologists increasingly frequently in the differential diagnosis of folliculitis. 10

      Folliculitis treatment

      General measures

      Avoid precipitating factors such as:

      • Inappropriate clothing.
      • High humidity.

      Try to observe the following routine:

      • Use moisturising shaving products and clean shaving implements with surgical spirit.
      • Alternatively, reduce frequency of shaving and ensure shaving ‘with the grain’ (or grow a beard).
      • Maintain good skin hygiene with non-allergenic cleaning agents.
      • Use separate washing implements and towels from other members of the household.

      Pharmacological

      • Consider treating nasal carriage of S. aureus with topical Fucidin® in those with recurrent folliculitis.
      • Mild, superficial folliculitis may resolve without treatment.
      • Topical antiseptics such as triclosan, clorhexidine or povidone-iodine may be used to treat and prevent superficial folliculitis.
      • For deeper folliculitis, topical or oral antibiotics are usually required; preferred agents are flucloxacillin, erythromycin or cephalosporins/mupirocin ointment.
      • In severe or recurrent cases, antibiotic therapy may be required for 4 to 6 weeks.
      • Other antibiotics may be used depending on culture results and the degree of clinical suspicion of alternative causative organisms – eg, pseudomonal folliculitis responds to oral ciprofloxacin.
      • Gram-negative folliculitis can be treated as for severe acne, with isotretinoin but use of isotretinoin is associated with major side-effects, including birth defects. 11
      • Deep folliculitis caused by MRSA can be treated with vancomycin or linezolid.
      • Fungal infections are usually treated with topical azoles – eg, clotrimazole or oral ketoconazole.
      • Aciclovir or similar agents can be used to treat herpetic folliculitis.

      Surgical

      Deep folliculitis can sometimes lead to the formation of carbuncles which may need incision and drainage.

      Prognosis

      Nearly all cases will resolve or respond to therapy without sequelae. Cases affecting the immunocompromised and those that are deep or recurrent are more likely to lead to complications.

      Complications of folliculitis

      • Recurrence.
      • Scarring.
      • Keloid formation.
      • Development of furuncles and carbuncles.
      • Abscess formation.
      • Systemic illness secondary to spread of infection (rare but more likely in the immunocompromised).
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