Folliculitis Organism-Specific Therapy 

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Before a treatment plan is devised, it is important to consider the etiology of the folliculitis and the severity and distributions of the lesions.

Organism-specific therapeutic regimens for folliculitis are provided below, including those for Staphylococcus aureus, methicillin-resistant organisms, Pseudomonas aeruginosa, Klebsiella, Escherichia, Serratia marcescens, Proteus, Malassezia furfur, Trichophyton, herpes simplex virus, and eosinophilic pustular folliculitis.

Topical antiseptics:

Topical antibiotics ^{[3, 4]} :

Clindamycin or erythromycin lotion, solution, or gel applied BID to affected areas until lesions resolve or

Bacitracin or mupirocin ointment applied BID to affected areas until lesions resolve

Mupirocin ointment can also be applied to nasal vestibule BID for 5d to eliminate the S aureus carrier state ^[5]

Systemic antibiotics ^{[3, 4, 6, 7]} :

Dicloxacillin 250 mg PO q6h for 7-10d or

Cephalexin 250-500 mg q6h for 7-10d

If the infection is caused by a methicillin-resistant S aureus (MRSA) organism, then antibiotic selection should be based on sensitivity testing and includes clindamycin, trimethoprim-sulfamethoxazole, minocycline, doxycycline, or linezolid. More recently, daptomycin, tigecycline, telavancin ceftaroline, dalbavancin, oritavancin, and tedizolid phosphate all have gained FDA approval for treatment of skin and soft-tissue infections. ^{[7, 8, 9, 10, 11, 12, 13]}

For severe deep infections not amendable to incision and drainage or for patients with infections resistant to the above antibiotics (methicillin-susceptible S aureus [MSSA]), consult with an infectious disease specialist and consider linezolid 600 mg q12h for 10-14d. However, use of this agent is limited owing to cost and toxicity.

Rifampin has excellent activity against MSRA and can be used in combination with one of the above agents. It should not be used as monotherapy owing to the rapid development of resistance to this agent.

See the list below:

Klebsiella, Escherichia,Serratia marcescens, and Proteus:

Trimethoprim-sulfamethoxazole (160 mg/800 mg) 1 DS tablet BID for 10-14d or

Ampicillin 250-500 mg q6h for 10d or

Isotretinoin 0.5-1 mg/kg/day for 4-5mo

Topical antifungals:

Topical therapies are most useful as adjunctive therapy with oral antifungals, as well as for maintenance and prophylactic therapy since often there is a tendency for recurrence.

Ketoconazoleor selenium sulfide shampoos used as a body wash daily or

Ciclopirox olamine suspension gently massaged into the affected and surrounding skin areas BID or

Econazole cream or foaming solution applied BID for 2-3wk

Systemic antifungals:

Fluconazole 100-200 mg/day for 3wk or

Itraconazole 200 mg/day for 1-3wk

Topical agents:

Systemic agent:

Systemic therapy should only be used in symptomatic patients resistant to the above therapies and who have a biopsy-proven infection.

Trichophyton species

Micronized griseofulvin 500-1000 mg/day for 4-6wk or

Ultramicronized griseofulvin 500-700 mg/day for 4-6wk or

Itraconazole 200 mg BID for 1wk monthly for 2 pulses or

Terbinafine 250 mg/day for 2-3wk

Herpes simplex virus  ^[17]

Acyclovir 200 mg 5 times daily for 5-10d ^{[18, 19]}  or

Valacyclovir 500 mg TID for 5-10d or

Famciclovir 500 mg TID for 5-10d

This condition is not due to an infection; therefore, it does not respond to systemic antibiotics. ^{[20, 21, 22]}

Treatments used with variable success:

Betamethasone valerate 0.1% applied BID for 3-24wk or

Tacrolimus BID for 3-24wk or

Isotretinoin 0.5 mg/kg/day for 4-8wk or

Itraconazole 200-400 mg/day PO for 2-3wk or

Metronidazole 250 mg PO TID for 4wk or

Indomethacin 25-50 mg/day PO for 1-8wk or

Broadband UV-B phototherapy 3 times weekly for 3-6wk or

Cetirizine 20-40 mg PO BID as needed for pruritus

Nonsteroidal anti-inflammatory agents such as ibuprofen 200 mg PO q6h for 1-8wk

Most cases of folliculitis are diagnosed clinically, but cultures with sensitivities, Gram stain, potassium hydroxide (KOH), or biopsy can be obtained if lesions do not resolve with empiric therapy.

Nasal cultures should be performed if S aureus colonization is suspected. If infection/colonization persists despite appropriate therapy and treatment of household members, cultures from nonnasal sites (axillary, inguinal, and rectal) should be considered. ^[5]

Family members also may be nasal carriers of S aureus; recommend the use of mupirocin ointment applied to the nasal vestibule BID for 5d and/or rifampin 600 mg/day PO for 10d, which may eliminate the carrier state ^{[4, 19]}

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Hara D, Kuroda K, Mieno H, et al. Treatment of eosinophilic pustular folliculitis with tacrolimus ointment. J Am Acad Dermatol. Nov 2004. 51(5 Suppl):S143-5.

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Elizabeth K Satter, MD, MPH Dermatologist and Dermatopathologist

Elizabeth K Satter, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Medical Womens Association

Disclosure: Nothing to disclose.

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Folliculitis Organism-Specific Therapy 

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