Signs and Symptoms

Patients with folliculitis have scattered pustules and small red papules centered around hair follicles. Lesions may be mildly pruritic or painful. Systemic symptoms are very rare.

Pustules are confined to hair follicles, typically in one region of the body such as the chest, thighs, or back. However, follicles throughout the body can become infected over the course of a few days. In bacterial infections, most pustules still have a hair shaft protruding from the center. There may be some surrounding erythema and slight swelling.

Main Causes

Staphylococcal Folliculitis: Staphylococcal infection should be suspected if erythema, swelling, and tenderness are striking. If needed, culture should be performed by shaving a pustule with a scalpel and sending the whole pustule for culture. Oral antibiotics are preferred when staphylococcal infection is suspected.

Gram-Negative Folliculitis: The gram-negative organisms Klebsiella, Enterobacter, and Proteus can also cause folliculitis. Infection typically occurs on the faces of acne patients treated with long-term antibiotics active against gram-positive organisms. Topical erythromycin is usually effective. Severe cases are treated using amoxicillin-clavulonate (Augmentin) or even isotretinoin (Acutane).

Hot Tub Folliculitis: Folliculitis acquired from wet objects such as hot tubs, whirlpools, loofah sponges, or wet suits is usually caused by Pseudomonas aeruginosa. Lesions appear on exposed areas of the trunk and extremities between 6 and 72 hours after contact. In immunocompetent patients, lesions typically resolve spontaneously within 10 days. Treatment is not required, but the source should be cleaned and new tub water properly sanitized. Pseudomonas in a loofah sponge is killed when the sponge is simply allowed to dry completely. Soaks in 1% to 5% acetic acid, topical silver sulfadiazine cream, or garamycin cream may be helpful. If needed, systemic fluoroquinolones can also be used.

Treatment

Topical antibiotics work well in most cases of superficial bacterial folliculitis. Antibiotics should be targeted against the presumed etiologic organisms. Therapy should be continued until lesions resolve.

If follicles are widely distributed, systemic antibiotics can be used.

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