Folliculitis

The Skin Center

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Folliculitis
 

What is folliculitis?

Folliculitis is a very common skin disorder seen in all kinds of people of all ages. It is a benign condition, which appears as numerous small red or pink little bumps around hair follicles on any part of the skin including the chest, back, arms, legs, buttocks, and  cheeks. It may create very small pus bumps around hair follicles, or a pink to red or “chicken skin” appearance on the skin. Although it is primarily a skin condition of teenagers and younger adults, folliculitis is also seen in all ages.

Many people with folliculitis are unaware that the skin condition has a designated medical term or that it is treatable. In general, folliculitis is often cosmetically displeasing and otherwise medically harmless. Many cases of folliculitis may resolve spontaneously without any treatment. Folliculitis is frequently noted in otherwise healthy patients visiting physicians such as dermatologists for other conditions. Treatment may typically include one or a combination of antibacterial washes, antibiotics creams or lotions, and antibiotic pills.

Who gets folliculitis?

Anyone can get folliculitis anywhere on the body where hair follicles are present. Humans have hair follicles on their entire body except on the palms and soles. Folliculitis is estimated to affect more 10-20% of people at some point in their lives. 

Certain groups of people are more prone to folliculitis. Diabetics and those with a compromised immune system like in HIV/AIDS, hepatitis, chronic illnesses, cancer, systemic chemotherapy, immunosuppressive drugs like prednisone, and those on biologic immune system modifying drugs like Remicade or Enbrel may be more prone to folliculitis.

What is the prognosis with folliculitis?

The prognosis with folliculitis is very good. Overall, folliculitis tends to be an easily treated and curable skin condition.  Commonly, it is a mild, benign, usually non-contagious, and self-limited skin condition. More widespread, atypical cases of folliculitis may be cosmetically disfiguring and psychologically distressing for the patient.

Does folliculitis affect the entire body?

The lesions in folliculitis most characteristically involve the chest, back, and legs. Other common locations include the face, neck, thighs and buttocks. Although possible, it is rare to have it all over the body. It does not affect the eyes, mouth, palms, or soles where there are no hair follicles.

What does folliculitis look like?

Photos of folliculitis patients show very small, often pinpoint red or pink bumps at each hair follicles. These small pus bumps or dry red bumps are often scattered over an area. Often, 10-100 very small slightly smooth bumps are scattered in a body area like the back. Some of the bumps may be slightly red or have an accompanying light-red halo indicating inflammation.

Sometimes, scratching off the top reveals a small trapped or coiled hair beneath the bump. Acne white heads called milia may also be in the same areas as folliculitis. Patients may complain of small red bumps and “acne” on their skin.

What causes the small bumps in folliculitis?

The bumps seem to arise from the inflammation at the small hair follicles. Sometimes there are common skin bacteria like staphylococcus or pseudomonas in the follicles. The upper skin layers may have some dilation of the small superficial blood vessels, thereby giving the skin a red or flushed appearance.

How is folliculitis diagnosed?

The diagnosis of folliculitis is typically very straightforward and based on the skin appearance.  In some cases, a small skin biopsy may be used to help the doctor confirm the diagnosis. Other times, a skin bacterial culture may be taken by a cotton tip applicator to assist in determining an infectious cause of the folliculitis. A few other medical conditions may look just like folliculitis and need to be examined more closely by a physician specializing in conditions of the skin called a dermatologist.

What else could folliculitis look like?

Other medical conditions can mimic folliculitis. Some possible look-alike skin conditions include keratosis pilaris, acne, milia (whiteheads), eczema, impetigo, atopic dermatitis, facial rosacea, contact dermatitis, fire ant bites, heat rash (miliaria), insect bites, sea bather’s eruption, or dry skin (xerosis).

Less common mimickers include chicken pox, herpes, pustular psoriasis, molluscum contagiosum, viral warts, Fox-Fordyce Disease, Graham-Little-Piccardi-Lasseur Syndrome, pruritic papular eruption of HIV disease, and erythema toxicum neonatorum. Folliculitis may also resemble uncommon skin conditions like lichen spinulosus, pityriasis rubra pilaris, phrynoderma (vitamin A deficiency), ulerythema oophryogenes, ichthyosis vulgaris, eruptive vellus hair cysts, ethromelanosis follicularis faciei et colli, keratosis follicularis (Darier Disease), Kyrle Disease, lichen nitidus, lichen spinulosus, perforating folliculitis, and trichostasis spinulosa.

What causes folliculitis?

Folliculitis is a basic problem with inflammation of hair follicles. This inflammation may be caused by simple irritation, infections like bacteria and yeasts, or other non-infectious skin conditions.

What is hot tub folliculitis or Jacuzzi folliculitis?

Hot tub folliculitis is a very common inflammation of the hair follicles on the trunk. It is seen a few days to weeks after someone has been soaking in a hot tub or Jacuzzi. It is most common on the back. Hot tub folliculitis photos show scattered pinpoint, small red to purple bumps all over the back or trunk. These may be very itchy or have no symptoms at all. Typically, there is a history of sitting for 1-3 hours in a hot tub days prior to the start of the bumps.

Hot tub folliculitis is thought to be caused by Pseudomonas bacteria, which frequently thrives in the hot temperatures of hot tubs. It is also called Pseudomonas folliculitis. Often, this type of folliculitis may clear on its own in a few days without treatment. Cases that do not clear spontaneously or with simple topical antibacterial washes are often treated with oral antibiotics like ciprofloxacin (Cipro), or levofloxacin ( Levaquin) for 5-14 days depending on the severity. The hot tub should be tested and possibly treated by trained pool and spa personnel for bacterial overgrowth. Affected patients may be more prone to recurrences in the future and should be cautious about hot tub use. 

What is razor burn folliculitis?

Razor burn folliculitis is very common on legs of women caused by shaving. It may also be seen on the face and necks of men. Typically, repeat tiny cuts caused by the razor on the skin often create small openings. The minute openings may then allow bacteria to enter the skin and invade the deeper hair follicles. Additionally, overly close shaving may cause trapping of small hairs beneath the skin surface causing more inflammation.

Treatment involves stopping shaving with a razor for a few days to weeks and using antibacterial washes and topical antibiotics. Alternative treatments may  include laser hair removal, electrolysis, electric razors, or cream depilatories like Neet or Nair.

What is pseudofolliculitis barbae?

Pseudofolliculitis barbae is a very common ingrown hair condition on the beard area (lower face and neck) of men. Typically, there are groups of 5-40 small red bumps on the beard area that may flare with repeat shaving.  Pseudofolliculitis tends to be worse in darker skin or African skin. The repeat tiny cuts caused by overly close shaving create possible ingrown or trapped hairs. These trapped hairs may cause irritation and inflammation at the hair follicles. Generally, this condition is not caused by bacteria.

Treatment goals include avoiding overly aggressive shaving, trial of the “bumps-free razor”, and antibacterial benzoyl peroxide shaving gels. Other treatment options include professional laser hair removal, electrolysis, electric razors, or cream depilatories like Neet or Nair.

Is folliculitis curable?

Most cases of folliculitis are easily and fully curable. There are very uncommon, long-standing cases of folliculitis that may not be curable. Often these more resistant cases may be controlled with proper treatment and medication.  It sometimes clears completely by itself without treatment.

Is folliculitis contagious?

Although most cases of folliculitis are not contagious, cases caused by an infection may be transmitted through person-to-person skin contact, use of fomites like razors, or through Jacuzzis or hot tubs.  Folliculitis may be sterile ( non-infectious) or caused by a fungus, bacterium, or virus. It is possible to give it to someone else through close skin contact. Some people are simply more prone to developing  folliculitis because of their overall health, possible altered immune status, exposure history, and other predisposing skin conditions like eczema or severely dry skin.

 

What are possible complications of folliculitis?

Complications are infrequent since folliculitis is usually a self-limited skin condition. Rarely, the bumps may enlarge causing an abscess (furuncles or carbuncles) or painful cysts requiring minor surgical drainage. Deeper or more extensive skin infections called cellulitis can be a  rare complication.

Another potential complication includes temporary skin discoloration called post-inflammatory hypopigmentation (lighter than the regular skin color) or hyperpigmentation (darker then the regular skin color). This altered skin color may occur after the inflamed, red bumps have improved or after a temporary flare.

Permanent scarring in uncommon but may occur from picking, overly aggressive scrubbing, or other deep inflammation.

Will I eventually outgrow folliculitis?

Folliculitis usually improves after the teen years and young adulthood. Most patients may expect a short course with easy clearing.

Are there any lab tests to help diagnose folliculitis?

Usually, no specific laboratory tests are needed in the diagnosis of common folliculitis. Imaging studies like x-rays or CT scans are not useful. A lab test called a bacterial culture may be useful to check for bacteria on the skin. Microscopic skin tests and fungal tests using potassium hydroxide may help to determine if the folliculitis is caused by yeast or a fungus. Skin biopsy (surgically taking a small piece of skin using local numbing medicine) with histopathological (exam of tissue under the microscope) evaluation may be useful in atypical or widespread cases. Sometimes skin biopsies help to exclude other possible diagnosis.

What does folliculitis look like under the microscope?

Microscopic examination of the body tissue under magnification is called histopathology or pathology. Histopathology of folliculitis shows the epidermis with mild hyperkeratosis (thickening of the skin epidermis), clustering of white blood cells around the hair follicle, and possible bacteria in the follicles. The upper dermis (layer of the skin) may have some microscopic inflammation called mild superficial perivascular lymphocytic inflammatory changes.

Does diet have anything to do with folliculitis?

Overall, diet does not seem to affect folliculitis. Some studies have evaluated a potential association of drinking milk with acne and possibly folliculitis. Vitamin A deficiency may cause similar symptoms to folliculitis.

How do I treat folliculitis?

There are many treatment options and skin care recipes for treating folliculitis. The specific treatment depends on the cause of the folliculitis.

Home therapy for mild cases of bacterial folliculitis includes use of an over the counter anti-bacterial wash like benzoyl peroxide (Clearisil, Proactiv), chlorhexidine (Hibiclens), or Phisoderm twice a day. Best results may be achieved with combination therapy using topical products and antibacterial washes.

Holistic treatment for folliculitis may include soaking the affected area in a dilute tub of white vinegar (1 part vinegar to 4 parts of water) or soaking in a bathtub with very dilute Clorox bleach (1 quarter cup of Clorox bleach in a bathtub full of water).

Bacterial folliculitis may be treated with antibacterial skin washes, and topical and/or oral antibiotics. It is important to keep in mind that as with any condition, no therapy is uniformly effective in all people. Your doctor may need to help evaluate the cause of your folliculitis

Moderate cases of bacterial folliculitis may be treated by a routine of twice-daily application of a topical antibiotic like clindamycin lotion or metronidazole lotion. A 5 to 30 day course of an oral antibiotic like cephalexin, dicloxacillin, doxycyline, minocycline, tetracycline, ciprofloxacin, or levofloxacin may be used for cases that are more resistant. After initial clearing with stronger medications, patients may then be placed on a milder maintenance regimen using antibacterial washes and topical antibiotics. 

Treatment of folliculitis associated with dry skin should address the underlying dryness. General measures to prevent excessive skin dryness and breakdown such as using mild soap less cleansers are recommended for these cases. Lubrication with moisturizer lotions such as Cetaphil or Lubriderm is helpful for many cases. Additional available  therapeutic options for tougher cases of dry skin include lactic acid lotions (Amlactin, Lac-Hydrin), alpha hydroxy acid lotions (glytone, glycolic body lotions), urea cream (Carmol 10, Carmol 20, Carmol 40, Urix 40), and salicylic acid (Salex lotion)..

Occasionally, physicians may prescribe a short 7-10 day course of a medium potency, emollient-based topical steroid cream like triamcinolone once or twice a day for inflamed or itchy areas. Inflammatory folliculitis may also be treated with topical steroids and/or  immunomodulators like Elidel or Protopic. Although these creams are approved for atopic dermatitis and eczema, their use would be considered “off label” (non-FDA labeled use) for folliculitis. These may be used in more resistant cases where there is considerable skin redness or inflammation.

Fungal or yeast folliculitis is often treated with an antifungal shampoo or body wash like ketoconazole (Nizoral Shampoo) twice daily. More resistant or deeper fungal folliculitis may require the addition of a topical antifungal cream like lotrimin or terbinafine (Lamisil) and an antifungal pill like fluconazole (Diflucan).

Persistent skin discoloration called hyperpigmentation may be treated with prescription fading creams like hydroquinone 4%, kojic acid, and azelaic acid 15-20%. Over the counter fading creams with 2% hydroquinone may be available like Porcelana. Specially designed prescription creams for particularly resistant skin discoloration using higher concentrations of hydroquinone 6%, 8%, and 10% may also be formulated by compounding pharmacists.

Severe cases of folliculitis and acne have been treated with isotretinoin (Accutane) pills for several months. Accutane is generally a very potent oral medication reserved for severe, resistant, or scarring cases of acne. Its use in folliculitis would be considered off- label (not FDA approved) and not routine.

How do I prevent folliculitis?

Prevention efforts include good skin hygiene, avoiding unsanitary hot tubs and pools, not sharing razors, avoiding shaving too closely, changing out razors regularly, and keeping the skin moist and well hydrated.

Folliculitis at a Glance

  • Very common, benign skin disorder
  • Looks like scattered, pinpoint red bumps  
  • Affects all ages from babies to seniors
  • Most common in teens and young adults
  • Numerous, small smooth red little bumps around hair follicles
  • Most common on the chest, back, buttocks, and legs.
  • Creates a “goose bumps” or “chicken skin” appearance of the skin
  • Often seen in otherwise healthy patients
  • Easily curable in most cases
  • Frequently clears on its own without treatment
  • May require ongoing maintenance therapy
  • Often treated with antibacterial washes like benzoyl peroxide.
  • Resistant cases may need antibiotic pills to clear

Prevented by good skin hygiene and proper shaving techniques.

 


 

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