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Folliculitis

Folliculitides

Folliculitis is clinically defined as an active inflammation of one or more hair follicles found anywhere in the skin. The inflammation in folliculitis is often caused by Staphylococcus aureus and less commonly by Pseudomonas aeroginosa.


Presentation

In general, folliculitis presents with the following common cutaneous symptomatology among patients:

  • Clustering of red bumps in a skin region
  • Pustule formation or development of a white headed pimple at the base of the hair follicle
  • Pus formation with blisters or vesicles [6]
  • Crusting lesions with suppuration
  • Pain and tenderness felt on the lesion
  • Formation of a large swollen bump or mass 
  • Erythema formation with inflammation
  • Pain and pruritus at the lesion
  • Circinate plaque formation with central pustules 
  • Hypertrophic scarring 
Exposure to Contaminated Water
  • Abstract Pseudomonas folliculitis (PF) is a community-acquired skin infection, which develops after exposure to contaminated water such as whirlpools, swimming pools, water slides and hot tubs.[ncbi.nlm.nih.gov]
Military Personnel
  • Folliculitis has been frequently observed among military personnel on the site of their anthrax and small pox immunizations. There is no sexual or racial predilection for the common folliculitis.[symptoma.com]
Hodgkin's Disease
  • Pityrosporum folliculitis and severe pruritus in two patients with Hodgkin's disease. Arch Dermatol . 1993 Mar. 129(3):380-1. [Medline] . Cholongitas E, Pipili C, Ioannidou D.[emedicine.medscape.com]
Eruptions
  • Oral ivermectin, 12 mg, was given, and the eruption cleared within 24 hours.[ncbi.nlm.nih.gov]
  • Her eruption occurred at the time of elective ambulatory surgery when she was treated with pre and post-operative antibiotics.[ncbi.nlm.nih.gov]
  • Abstract Several inmates from a non-air-conditioned prison were sent to the University of Texas Medical Branch dermatology clinic for unexplained eruptions not responding to various treatments.[ncbi.nlm.nih.gov]
  • Abstract Neutrophilic folliculitis is an often overlooked chronic condition characterized by a monomorphic eruption of "sterile" papulopustules.[ncbi.nlm.nih.gov]
  • Abstract A 35-year-old man presented with a painful cutaneous skin eruption that was localized on the upper trunk. He stated that the previous weekend he had attended an Arabian bath.[ncbi.nlm.nih.gov]
Acne Vulgaris
  • The history and pathophysiology of gram-negative folliculitis in the setting of acne vulgaris is reviewed.[ncbi.nlm.nih.gov]
  • CONCLUSION: Unlike classic acne vulgaris, Pityrosporum folliculitis was more common after antibiotic use.[ncbi.nlm.nih.gov]
  • KEYWORDS: Gram staining; Malassezia folliculitis; Pityrosporum folliculitis; acne vulgaris; bacterial folliculitis[ncbi.nlm.nih.gov]
  • Deep- (usually granulomatous)- Fungi or bacteria II Non infectious- Superficial- (usually suppurative)- Acne vulgaris, rosacea , follicular mucinosis, steroid induced.[histopathology-india.net]
  • Abstract Malassezia (Pityrosporum) folliculitis is a fungal acneiform condition commonly misdiagnosed as acne vulgaris.[ncbi.nlm.nih.gov]
Follicular Rash
  • A 48-year-old man presented with a severely pruritic follicular rash for several months that started after reaching a complete molecular response of his myeloid chronic while treated with nilotinib.[ncbi.nlm.nih.gov]
  • METHODS: A 29-year-old man presented to our clinic with a 5-year history of an intermittent follicular rash. These eruptions occurred on his back and chest only when he was exposed to the sun, with his shirt off.[ncbi.nlm.nih.gov]
Follicular Rash
  • A 48-year-old man presented with a severely pruritic follicular rash for several months that started after reaching a complete molecular response of his myeloid chronic while treated with nilotinib.[ncbi.nlm.nih.gov]
  • METHODS: A 29-year-old man presented to our clinic with a 5-year history of an intermittent follicular rash. These eruptions occurred on his back and chest only when he was exposed to the sun, with his shirt off.[ncbi.nlm.nih.gov]
Exanthema
  • Like drug eruptions, viral exanthema, and toxic erythema of chemotherapy, Demodex folliculitis is a clinical mimicker of acute GVHD and requires nonimmunosuppressive therapy.[ncbi.nlm.nih.gov]
Meningism
  • It can cause meningitis, central nervous system abscess and sepsis, almost exclusively in infants and immunocompromised hosts. Respiratory tract and urinary infections have been reported in elderly people.[ncbi.nlm.nih.gov]
  • Complications include abscess formation, persistent blindness, limited eye movement, diplopia, and, rarely, meningitis. 11 This ocular emergency requires intravenous antibiotics, otorhinolaryngology, and ophthalmologic consultation. 12 Perianal cellulitis[aafp.org]
Intracranial Hemorrhage
  • Abstract Intrauterine infections are associated with life-threatening neonatal conditions such as sepsis, intracranial hemorrhage, and chronic lung disease.[ncbi.nlm.nih.gov]

Workup

A complete and detailed clinical history of the lesion will give away the diagnosis of folliculitis to the primary physician. Laboratory tests are not the primary workup procedure, and are ordered only when the history and physical examination doesn't lead easily to diagnosis. When the empiric treatment appears to be unresponsive, swabs of the secretions may be taken for culture and sensitivity to determine the causative agent and its respective sensitivity to antibiotics [7]. Skin biopsy may sometimes be done to rule out other cutaneous disease conditions [8].

Citrobacter Koseri

Treatment

In general, the treatment of choice for folliculitis is greatly dependent on the severity of the disease. For mild folliculitis, antibiotic creams (mupirocin) may be used while oral antibiotics (cephalexin) for 7 to 10 days may be given for recurrent cases. For fungal folliculitis, topical antifungals may be used for folliculitis caused by yeasts and fungus like those seen in Pityrosporum folliculitis. For autoimmune or eosinophilic folliculitis, patients may be given steroid creams (betamethasone) and oral corticosteroids for severe inflammation.

Patients presenting with large boils and carbuncles may be surgically incised and drained to reduce the scarring of the skin and other complications. Light and laser therapy are reserved for refractory cases of folliculitis which are not responsive to common treatment modalities [9].

Prognosis

Superficial folliculitis almost always resolves without any intervention or treatment. Severe forms of folliculitis may respond well with treatment but there is a very high recurrence rate. Mortality from primary folliculitis is rare. There is increasing morbidity coupled to severe complications like cellulitis, chronic scarring, furunculosis, abscess formation, carbuncle formation, and permanent hair loss.

Etiology

Folliculitis is most often caused by the bacterium Staphylococcus aureus. This cutaneous infection could further be classified as either superficial or deep depending on how much hair follicle is involved. The deeper the folliculitis the more severe the disease conditions and the more complicated is its clinical course and treatment. Any break in the integrity of the follicles can predispose it to bacterial, viral or fungal infections. The following everyday conditions are associated with follicular damage:

  • Inflammatory skin conditions like acne and dermatitis
  • Skin incisions from surgery or scrapings
  • Unhygienic coverings of the skin like old plaster dressing and adhesive tapes
  • Sweating and heat caused by wearing booties, waders, and rubber gloves
  • Friction from shaving and tight clothing

Epidemiology

The occurrence of superficial folliculitis is very common all over world. Because most cases resolve spontaneously, only a few cases are brought to the physician for medical care and recording. Patients are found to be more susceptible to folliculitis if they are diabetics, on immunosuppressive drugs, having preexisting dermatoses, on long term antibiotics use, on chronic anti-retroviral therapy [1], and on chronic occlusive dressings. Folliculitis has been frequently observed among military personnel on the site of their anthrax and small pox immunizations [2].

There is no sexual or racial predilection for the common folliculitis. Although, the incidence of pseudofolliculitis or traction folliculitis are more common among Afro-Americans [3], while the Japanese are more prone to the eosinophilic type of folliculitis [4]. Folliculitis may also occur in all age groups.

Sex distribution
Age distribution

Pathophysiology

Superficial folliculitis may occur due to hair follicle occlusion or direct trauma to the follicles. In can also occur as a secondary infection after a primary cutaneous infection spreads contiguously towards the hair follicle. Autoimmune forms of folliculitis or eosinophilic folliculitis are postulated to occur due to the antibodies that attack the sebum and the sebocytes (fat cells) of the body. Theories have been brought to light that the papulopustular eruptions that occur in superficial folliculitis are due to the abnormal epidermal differentiation that leads to follicular obstructions and inflammations [5].

Prevention

Folliculitis may easily prevented from recurring if the underlying disease is treated and controlled like those with diabetes mellitus and tuberculosis. Patients with recurrent barber’s itch on the mustache area may opt not to shave them and grow beards instead. The use of shaving creams may brace the skin and prevent follicular damage in the process.

Folliculitis occurring in areas of high friction may be avoided by loosening the garment or fabric that causes the perennial friction. Rubber gloves must be thoroughly cleaned and dried in between uses to prevent skin infections. Cleaning of hot tubs with chlorine can help prevent the propagation of the bacteria Pseudomonas aeroginosa that can infect the skin [10].

Summary

Folliculitis is a very common skin infection that starts at the hair follicles of the skin. Folliculitis is sometimes referred to as hot tub rash, razor bumps, and barber’s itch. It is caused by various microorganisms. It is usually brought about by bacterial, viral (herpes), or fungal (yeast) infections. The infection may start as a reddish macule or a white headed pustule but can later complicate into a non-healing and crusting lesion. Milder forms of folliculitis will present with a sore and itchiness while severe forms of folliculitis may cause scarring and permanent hair loss in the affected area.

Patient Information

Definition

Folliculitis is clinically defined as an active inflammation of one or more hair follicles found anywhere in the skin.

Cause

Any break in the integrity of the skin, and infected by bacteria, virus, and fungal etiologic agents.

Symptoms

Symptomatology ranges from red painless sore to an exudative blistering abscess.

Diagnosis

A complete clinical history and direct physical examination of the skin, skin swab for culture and sensitivity testing [11] may be used to diagnose the condition.

Treatment and follow-up

Patients are given topical and oral antibiotics and anti-fungal agents. Phototherapy and laser therapy.

References

Article

  1. Okada S, Fujimura T, Furudate S, Kambayashi Y, Kikuchi K, Aiba S. Immunosuppression-associated eosinophilic pustular folliculitis (IS-EPF) developing after Highly Active Anti-Retroviral Therapy (HAART): the possible mechanisms through CD163+ M2 macrophages. Eur J Dermatol. Sep-Oct 2013; 23(5):713-4.
  2. Walsh SR, Johnson RP. Vaccinia Folliculitis after Primary Dryvax Vaccination. Infect Dis Clin Pract. Mar 2007; 15(2):132-4.
  3. Fox GN, Stausmire JM, Mehregan DR. Traction folliculitis: an underreported entity. Cutis. Jan 2007; 79(1):26-30.
  4. Nervi SJ, Schwartz RA, Dmochowski M. Eosinophilic pustular folliculitis: a 40 year retrospect. J Am Acad Dermatol. Aug 2006; 55(2):285-9.
  5. Bragg J, Pomeranz MK. Papulopustular drug eruption due to an epidermal growth factor receptor inhibitors, erlotinib and cetuximab. Dermatol Online J. 2007; 13(1):1.
  6. Boer A, Herder N, Winter K, Falk T. Herpes folliculitis: clinical, histopathological, and molecular pathologic observations. Br J Dermatol. Apr 2006; 154(4):743-6.
  7. Weedon D, Strutton G. Skin Pathology. 2nd Ed. New York, NY: Churchill Livingstone; 2002:459-66.
  8. Weinberg JM, Mysliwiec A, Turiansky GW, Redfield R, James WD. Viral folliculitis. Atypical presentations of herpes simplex, herpes zoster, and molluscum contagiosum. Arch Dermatol. Aug 1997; 133(8):983-6.
  9. 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.
  10. Yu Y, Cheng AS, Wang L, Dunne WM, Bayliss SJ. Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa. J Am Acad Dermatol. Oct 2007; 57(4):596-
  11. Nervi SJ, Schwartz RA, Dmochowski M. Eosinophilic pustular folliculitis: a 40 year retrospect. J Am Acad Dermatol. Aug 2006;55(2):285-9.

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Last updated: 2017-08-09 17:33