Folliculitis and Skin Infections

Folliculitis is an infection of the hair follicle that is most commonly bacterial, but can occasionally be caused by a fungus. It can be either superficial in the follicle or deep in the skin.

There are also forms of folliculitis which are non-infectious such as those caused by tars, oils and greases that come into contact with the skin.

When, Where, And Who Gets Folliculitis?

Superficial staphylococcal folliculitis is quite common and is seen in people of all ages. It is probably more common in those who have eczema and diabetes. You might see it on your face, scalp, upper trunk, buttocks, or as a sty on your eyelids.

Deeper staphylococcal folliculitis is uncommon and may be seen as boil-like lesions in diabetics. There is also a condition called sycosis, which is a pustular folliculitis, particularly in the bearded area of men.

Gram-negative folliculitis is only rarely seen, usually on the face of those who have been taking antibiotics on a long-term basis for acne. Gram-negative folliculitis is most often seen in people who have been in a hot tub or whirlpool that has been contaminated by the bacteria pseudomonas.

Fungal Folliculitis:

Trichophyton folliculitis is mostly seen in women who shave their legs, presumably spreading this from their athlete’s foot fungal infection.

Pityrosporum folliculitis is usually located on the upper back and shoulder of young people. It is more common in individuals who are immunosuppressed.

Candida folliculitis can be seen on the scalp and in occluded moist areas, such as under the breasts and in the groin areas of people who are obese.

Lab Tests:

Swabbing the skin, then sending it to a laboratory for bacterial and yeast cultures will confirm the infection.

A skin biopsy may be required to confirm deep fungal of yeast folliculitis.

Blood sugar tests and/or HIV testing should be done for those who have repeated infections or an infection that does not have the typical symptoms

What Can I Do About My Folliculitis?

Self help:

Good hygiene with regular hand washing is a must to minimize the risk of staph infections. Keeping your skin healthy and avoiding factors that can over-dry your skin, causing it to crack should be avoided. Picking and squeezing the skin causes minor damage, which in turn makes it easier for infection to set in. A skin that is clean and intact with no abrasions or sites of friction or irritation is less likely to become infected. In some circumstances, there may be a role for antibacterial cleansers. Hot tubs need to be checked regularly for pH and antiseptic levels.

Medical treatment:

If you think you have folliculitis, the most important thing for you to do is to see your doctor in order to confirm the diagnosis, so that you can seek folliculitis treatment. Ideally, the organism causing the infection should be identified and its sensitivity to antibiotics should be established.

Sometimes, your doctor will treat an infection based on his or her clinical suspicion, especially if the appearance is typical.

Bacterial folliculitis can be caused by the following bacteria

• Staphylococcus aureus
• Gram-negative bacteria

Pseudomonas (hot tub folliculitis)

• E. coli
• Klebsiella
• Fungal /yeast folliculitis
• Candida albicans
• Pityrosporum ovale
• Trichophyton rubrum

Topical treatments:

Topical antibiotics and antifungal creams to treat staphylococcal folliculitis:

The choice of folliculitis treatment will depend on the cause of the infection as well as how deep and extensive it is. Topical antibiotics should be used in the short term to minimize the risks of bacterial resistance.

Topical antibiotics can clear superficial localized infections. The affected area should be treated with the appropriate cream or ointment two or three times a day. Chronic staph can be carried inside the nose, and can be a factor if the infection recurs. In such a case, nightly application of the ointment inside the nose will clear the reservoir of the bacteria. Oral antibiotics will be required if there is an inadequate response.

1) Fusidic acid:

Fusidic acid is an antimicrobial that was isolated by Godtfredsen, et al, in Europe from the fermentation of Fusidium Coccineum. It was introduced into clinical practice in 1926, as an oral drug. About twenty years later, it was introduced in Canada as a topical drug.

How do I use this medication?

Fusidic acid is available both as a cream and as an ointment. You should apply it thinly on to the infected area 3-4 times daily.

How does it work?

Fusidic acid inhibits protein synthesis in the bacteria and without that capacity, the bacteria will die. The topical formulation penetrates a damaged, infected horny layer better than intact skin. It is related to the cephalosporin, an antibiotic produced by Cephalosporium, a genus of fungi.

Will there be side effects?

Side effects from the topical preparations are very uncommon. There have been no human tests done during pregnancy and lactation, but there have been no adverse reports.

Can I take other medications?

There are no interactions from the topical formulation of fusidic acid.

Which brands are available?

• Fucidin® 2% cream and ointment available as well as Fucidin HCl®, which is combined with 1% hydrocortisone acetate
• Fucidin Intertulle® - impregnated into a gauze
• IV, tablets and oral suspension (250mg/5ml) are available, IM and subcutaneous administrations are too irritating

2) Mupirocin:

A natural product of Pseudomonas fluorescens that has antibacterial actions against gram-positive bacteria such as Staphylococcus and Streptoccus. It has some activity against gram-negative organisms. It is inactive against anaerobic bacteria chlamydia and fungi.

How do I use this medication?

Mupirocin is available both as a cream and an ointment. You should apply it thinly on the affected area 3 times a day for up to 10 days. It may be used on all ages except for in the USA where the Bactroban nasal ointment is not recommended for children under the age of 12.

How well does it work?

Mupirocin is easy to apply and is very effective against the common skin pathogens such as Staphylococcus and Streptococcus. It works well for impetigo as well as bacterial folliculitis. The incidence of resistance remains low. For localized impetigo it works as well as oral antibiotics in 90% of cases. It is not effective against Pseudomonas or fungi. It is useful in the treatment of chronic Staph carriage in the anterior nares (nose).

How does it work?

It is unlike other antibiotics in that it inhibits bacterial isoleucyl transfer-RNA synthetase blocking protein synthesis. It is bacteriostatic at low concentrations and bacteriocidal at high concentration. There is virtually no systemic absorption via intact skin and anything that is becomes metabolized to monic acid and quickly removed by the kidneys.

Will there be side effects?

Local:

Dry skin, swelling, burning pain itch and rash. The effects are usually mild. Allergic reactions are rare. Polyethylene glycol will be irritating if the ointment is used around the eyes.

Systemic:

Renal toxicity from absorption of the polyethylene glycol vehicle (ointment only) if large amounts are used in open wounds or burns.

Which brands are available?

• Bactroban ointment 2% mupirocin (polyethylene glycol base)
• Bactroban cream 2% mupirocin (oil-water based emulsion)
• Bactroban Nasal - for the nose and is in a white paraffin/glycerin base (not available in Canada)

What conditions are treated by this medication?

• Skin staphyococcal infections including impetigo, folliculitis, burns, and wounds
• It is also used to treat streptococcal infections