Folliculitis – Causes and Treatment

Folliculitis can be defined as inflammation of the hair follicles. The presence of inflammatory cells inside the wall and ostia of the follicles clears the diagnosis of foliculitis. All the signs of inflammation are present like redness of the area, itching, increase in local temperature and there is formation of pustules as well. The types of inflammatory cells present in the folliculitis vary according to the source of inflammation and if any biopsy material is obtained for examination under microscope, the stage of the inflammation. Initially, there is inflammation of the infundibulum of the follicle. Later stages, the inflammatory process go deeper into the structure and can produce scar. Folliculitis is not related to age and sex but the Japanese and the Afro-Americans are more prone to this disease.

Folliculitis can appear any area of the body skin but the arms, legs, chest, cheeks and buttocks are mostly affected. Several smooth bumps appear over a particular area giving it a ‘chicken skin’ appearance. Some of these raised areas have a surrounding red halo which indicates active inflammatory process. Other skin disease like acne and milia can accompany the same area with folliculitis.

By and large, folliculitis is a self-limiting disorder and does not cause any harm to the skin. Treatment of folliculitis depends upon the cause and usually comprise with topical and systemic antibiotics with corticosteroids. Here, we shall discuss about different causes and the specific treatments of folliculitis.

• Staphylococcus aureus – this bacterium is, by far, is the most common causative agent of folliculitis. Bacteria present in the outer layer of the skin can sometimes get triggered by underlying diseases. Decreased immunity, diabetes mellitus, chronic debilitating diseases like cancer and tuberculosis are risk factors for these bacteria to flare up. Bacteria penetrate the infundibulum of the hair follicle and in presence of suitable conditions they multiply and affect the follicle. Staphylococcal folliculitis usually affects the maximum skin area. There is itching and redness of the skin. At a later stage, there is formation of pus inside the follicle and skin bumps mount. Treatment of Staphylococcal folliculitis comprises of systemic antibiotics like amoxicilline, cloxacilline, dicloxacilline, flucloxacilline usually for 5-7 days and topical antibiotic-steroid preparation like mupirocin and fluticasone combination. If the patient complains of intense itching, fexofenadine can improve the situation.

• Malassezia folliculitis – a specific group of fungi Malassezia furfur can bring out similar condition like staphylococcal folliculitis. There is intense itching and the affected areas of skin usually protrude as a whole instead of solitary bumps. The color of the affected area becomes pale yellow or white. In fungal folliculitis, the damage of the hair follicle is more than any other cause and there is fair chance of scarring. The treatment of fungal folliculitis constitutes of cleaning the affected area with normal saline and chlorhexidine solution. Topical antifungal agents like miconazole and ketoconazole can be applied. In refractory cases systemic antifungal drugs like itraconazole, ketoconazole and terbenafine are administered along with topical terbenafine cream. The duration of treatment varies from 7 days up to 2 weeks.

• Pseudomonas folliculitis – this is another form of bacterial folliculitis due to infection of the hair follicles by Pseudomonas aeruginosa, a gram-negative bacillus. This condition is also known as ‘swimming pool folliculitis’ or ‘Jacuzzi folliculitis’. This is a severe form of folliculitis where the patient also suffers from fever, generalized bodyache and sore throat. There may be gastrointestinal disorders as well. Pseudomonas folliculitis usually appears 6-36 hours after exposure to contaminated water usually in a swimming pool, not perfectly treated with chlorine. Follicles may arise any part of the body and they are painful. The condition usually self-limiting and wanes off after a week or two. However, relief from the fever and other associated symptoms is necessary. After the diagnosis is made from history and typical clinical findings, systemic antibiotics are started with cefixime and cefpodoxime. Fever and body ache can be neutralized with paracetamol, ibuprofen or diclofenac. If the patient complains about intense itching, fexofenadine is administered.

• Tinea barbae – infection of the hair follicle with Tinea rubrum is similar to staphylococcal folliculits and resembles ‘barber’s itch’. The common area of this type of folliculitis is groin and underarms. Hot and humid circumstances help in rapid multiplication of the fungus. This type of folliculitis generally affects young male farmers. The commonest area affected is chin and the skin below it. Typically one side of the face is involved and there is formation of pustules. Systemic antifungal agents like itraconazole and terbenafine is required to get rid of this condition.

• Razor folliculitis – this is another type of fungal folliculitis which affects the female who shave their skin. This condition may also affect the neck in case of men. Frequent shaving may lead to breach of the skin covering and the fungi penetrate through these areas. Quickly they infect the hair follicles and produce a boggy swelling. There is scarring and condition is called Majocchi granuloma. Treatment consists of stopping of shaving until the infection controls and topical antifungal-steroid combination, as required. If the problem recurs after resumption of shaving, electrolysis or laser ablation of the unwanted hair follicles can be considered. Waxing and cream depilatory preparations do not help much in this condition.

• Herpetic folliculitis – chicken pox virus can remain dormant in the nerve endings for years. With the suitable condition, this virus can flare up in the hair follicles around the lip and angle of the mouth. The condition is very much painful and fever and generalized body ache usually accompany the condition. Systemic antiviral agents like acyclovir along with topical acyclovir cream are beneficial in herpetic folliculitis.

• Gram-negative folliculitis – several gram-negative bacteria can infect the hair follicle in a patient with long term antibiotic therapy for other systemic conditions. Klebsiella, E. coli, Proteus sp, Serratia and Enterobacter are the common organisms present in gram-negative folliculitis. Small red colored pustules present in the cheek, chin and neck region represent this type of folliculitis. Oral antibacterial agents like erythromycin, roxithromycin, cefixime and cefpodoxime produce satisfactory results to manage this condition.

• Tufted folliculitis – this condition affects the hair of the scalp and is completely different from dandruff and other infective lesions. Origination of several hairs from a single follicle is the hallmark of this disease. After a certain period, these hairs fall off and there is localized baldness due to permanent scarring. Topical steroid preparation can help in this condition.

• Oil folliculitis – the condition is also known as allergic folliculitis. Exposure to certain allergic toiletries preparations and other chemicals can lead to inflammation of hair follicle. This comdition is common in sensitized females, workers in dye factory, refinery worker and shepherds. Stoppage of exposure to allergic chemicals can treat the condition.

These are the common causes of folliculitis and their treatment. Many of these conditions can be averted with personal hygiene and close observation of the affected area. Avoiding tight fitting clothes, shaving with care, maintaining proper cleanliness in the swimming pools and Jacuzzis and using suitable medicines are all needed to get rid of folliculitis.