Have you been experiencing small painful pimple-like lesions on the skin? You might be affected by folliculitis.
What is Folliculitis?
“Folliculitis is a common skin condition that appears as numerous small red or pick bumps at hair follicles.
Folliculitis is often cosmetically displeasing but medically harmless. Many cases of folliculitis resolve spontaneously without treatment. Folliculitis frequently affects otherwise healthy people. Typically, it is a noncontagious, self-limited condition.
When the skin swells and becomes pink or red close to hair follicles, an infection by Staphylococcus aureus may be occurring. Folliculitis are protuberances filled with an exudate popularly called ‘pus’, they range in size from 2 to 5 mm.”1
“Folliculitis of the skin may be superficial or deep, as in pyodermas caused by pyogenic organisms like S. aureus or due to other factors like irritation or occlusion. However, there are a number of inflammatory diseases involving the hair follicle, the etiology of which are complex or uncertain, with the role of a bacterial infection being partial, secondary, not known or absent. For example, these include conditions such as sycosis barbae and folliculitis decalvans. Dermatitis cruris pustulosa et atrophicans (DCPA) is a distinctive type of chronic superficial folliculitis, of complex etiology, seen primarily in tropical countries. It primarily affects the anterior shins, with recurrent crops of itchy follicular pustules, which resolve either spontaneously or with treatment, resulting eventually in atrophy and loss of hair over the affected skin. The disease typically responds to a variety of topical and systemic antibiotics but is characterized by recurrences that may be triggered by a variety of factors. Thus, DCPA has several unique features that distinguish it from banal pustular folliculitis, such as its peculiar localization to the legs, extreme chronicity, resistance to therapy and inevitable alopecia and atrophy of the involved skin, without any systemic symptoms.2
“Erythema and pustule occur at the hair follicle. The skin lesion forms a crust in several days and heals without scarring in most cases. Superficial folliculitis that causes multiple eruptions on the face especially in puberty is called acne vulgaris. Deep-seated folliculitis is accompanied by intense inflammatory symptoms and may progress to furuncle or carbuncle in some cases.”3
“Folliculitis decalvans (FD) is an inflammatory presentation of cicatrizing alopecia characterized by inflammatory perifollicular papules and pustules. It generally occurs in adult males, predominantly involving the vertex and occipital areas of the scalp. The use of dermatoscopy in hair and scalp diseases improves diagnostic accuracy. Some trichoscopic findings, such as follicular tufts, perifollicular erythema, crusts, and pustules, can be observed in folliculitis decalvans. More research on the pathogenesis and treatment options of this disfiguring disease is required for improving patient management. There is usually only one focus of the disease, which begins with painful follicular papules and pustules and spreads to the back. A large erythematous, thick and hardened alopecia plaque appears, with a centrifugal progression
The etiology of this inflammatory process is not fully understood. However, Staphylococcus aureus scalp colonization has been implicated as a contributing factor. It has been suggested that the mechanism of “superantigens” or cytotoxins that bind to class II MHC can play a role in the pathogenesis of the disease. The theory of genetic predisposition is supported by reports of FD familial cases.
The vertex and occipital areas of the scalp are especially involved. There is usually only one focus of the disease, which begins with painful follicular papules and pustules and spreads to the back. A large erythematous, thick and hardened alopecia plaque appears, with a centrifugal progression. The hallmark of FD is the development of scars and areas of follicular pustules. Follicular keratosis, erosions, and hemorrhagic crusts can be observed. Some patients occasionally report spontaneous bleeding, pain, itching or a burning sensation.
Tufted folliculitis is a common finding in FD patients, characterized by multiple hairs emerging from one single dilated follicular orifice (polytrichia). Bacterial cultures should be performed from an intact pustule, and a nasal swab with antibiotic sensitivity tests should also be done in order to identify an occult S. aureus strain.”4
What is Pseudomonas folliculitis?
“Pseudomonas folliculitis is an inflammation of the hair follicles caused by infection with the bacteria P. aeruginosa.
How soon after exposures do symptoms of Pseudomonas folliculitis appear?
The incubation period for “Pseudomonas folliculitis” is usually 48 hours (range 8 hours to 5 days) after exposure to contaminated water.5
What Does Folliculitis Look Like?
As illustrated, folliculitis can be seen as isolated or multiple red spots on the skin.
“Shaving irritation is a very common form of Staphylococcus aureus folliculitis induced by the little abrasions and ingrowing hairs caused by razor blades, both in men and women.” 6
“Folliculitis decalvans. A fibrotic erythematosus alopecia plaque with polytrichia (dolly hair)”7
What are Common Causes of Folliculitis?
Excessive itching and scratching, wearing tight-fitting garments, shaving, or suffering from health disorders, such as dermatitis, eczema, and even obesity. Some skin allergies, excessive exposure to wound dressings and bonding agents like sticky straps can also cause swelling of hair follicles.
It has been reported in persons using hot tubs, whirlpools, saunas, swimming pools, waterslides and physiotherapy pools.
Where is P. aeruginosa found?
Pseudomonas aeruginosa thrives in warm and moist areas and is commonly found in soil, sinks and drains, shower-floors, carpeting and even tap water.
- Warmer water temperatures enhance the growth of P. aeruginosa.
- Warmer water temperatures of whirlpools and hot tubs promote the expansion of the pores of the hair follicles allowing entrance to bacteria.
- Organic matter commonly found on human skin provides nutrients for P. aeruginosa to grow and multiply.
- Turbulence in the water interferes with the maintenance of disinfectant levels, especially in whirlpools made of wood.”8
Are You Likely to Develop Folliculitis?
Folliculitis can be suffered by everyone, regardless of gender or race. Although, people with pre-existing conditions such as diabetes, cancer, or HIV can develop folliculitis more frequently than others.
“Folliculitis is a superficial infection of the hair follicles, and is frequently found in areas of repeated shaving (“shaving irritation”). Folliculitis appears as clusters of small, red and itchy lesions, sometimes with a central pustule. Folliculitis is usually caused by the bacterium Staphylococcus aureus. Although people with diabetes or immune dysfunction are at the highest risk, mere colonization of the bacterium on the skin or in the nose – as is the case in 30-50% of all people – is a risk factor for recurrent infections
Who gets Pseudomonas folliculitis?
Any person exposed to water contaminated with P. aeruginosa can get Pseudomonas folliculitis.”9
Where Does Folliculitis Usually Show?
“Folliculitis is usually shown on the chin, beard, forearms, armpits, legs, scalp, or a combination of these. However, it can appear on any place where hair grows.
Folliculitis can affect any part of the skin, including the chest, back, arms, legs, buttocks, and cheeks.”10
What Are the Symptoms?
Folliculitis appears as swollen skin with spots full of pus, which can feel very itchy. It can turn very sore as the condition increases in severity. As it does so, profound skin infections occur along with issues such as cellulitis, dermatitis, and hair loss.
What are the symptoms of Pseudomonas folliculitis?
“Pseudomonas folliculitis first appears as itchy bumps and develops into dark red tender nodules and/or small pus-filled pimples. The eruptions typically involve the trunk and upper parts of the arms and legs. The rash can be extensive and may affect all areas of the body except the palms of the hands and soles of the feet. Headache, nausea, vomiting, abdominal cramps, sore throat may accompany the rash, rhinitis, sore eyes, and fever. The rash may be more severe under areas covered by a swimsuit where the material held the contaminated water in contact with the skin for a longer period of time.”11
How can Pseudomonas folliculitis be diagnosed?
“Pseudomonas aeruginosa can often be cultured from pus-filled pimples on the skin.”11
Treatment for Folliculitis
“Treatment may typically include one or a combination of antibacterial washes, antibiotic creams or lotions and antibiotic pills.
- A holistic treatment may include soaking the affected area in a tub of diluted white vinegar (1-part vinegar to 4 parts of water) or soaking in a bathtub with very diluted Clorox bleach (1/4 cup of Clorox bleach in a bathtub of water).
- If you have a bacterial folliculitis, the medical provider will prescribe topical antibacterial skin wash/lotion and/or oral antibiotics.
It will be important to use the medication as prescribed and complete the treatment.”12
What Can You Do to Prevent or Control it?
“To prevent folliculitis from reoccurring preventive efforts, include good skin hygiene. Avoid unsanitary hot tubs and pools, do not share razors, avoid shaving too closely, change out razors regularly, if shaving the genital area change the razor after each use and try to shave in the direction the hair grows and keep your skin moist and well hydrated. For recurrent episodes that do not respond to these measures consider using a depilatory product for hair removal.”12
The following actions can be taken to control mild manifestations of folliculitis:
- Do not shave over injured areas.
- Always keep hygienic habits when shaving.
- If possible, use a new disposable razor each time you shave.
- Don’t use tight-fitting clothes.
- Use mild antiseptic cleansers and shampoos.
- Maintain good hygiene by washing personal clothing and sanitary items as often as necessary.
How can Pseudomonas folliculitis be prevented?
“Proper maintenance and control of the pH and disinfectant levels will prevent the growth of “Pseudomonas folliculitis” in hot water supplies.”13
When Is Medical Attention Urgently Required?
“If your skin condition worsens, or if you develop whole body symptoms such as fever, chills, nausea or vomiting return to the Student Health Center or see another medical provider promptly.”13
A dermatologist should be visited urgently when the tips above do not help you in two to three days. Even more so if you are on antibiotics.
What Do Doctors Usually Prescribe for Severe Folliculitis?
Your doctor will probably prescribe skin care medication as well as antibiotics.
Before doing so, a bacterial culture is taken to determine the type of microorganism that is causing the infection by pinching the affected area with a needle to get a sample of the exudate. It is then collected with cotton swabs and lab-tested.
Some lab results will be obtained within a few days, but it can also take more than a week since sensitivity testing is required in order to determine which antibiotics will be most effective in eliminating the existing bacteria type. When lab results are available, the doctor can recommend the most adequate and specific-oriented treatment.
What is the treatment for Pseudomonas folliculitis?
“The rash associated with this infection will usually go away on its own and treatment may not be needed. ‘Anti-itch’ medications may be used to control the itching.
Folliculitis can resolve spontaneously if the pus is drained, but antibiotic therapy can be required, especially when boils proceed to skin abscesses. Topical mupirocine is often prescribed and in more severe infection, oral or intravenous antibiotics are used. With the rise of MRSA, treatment has become more and more of a challenge, as this superbug has developed resistance against most antibiotics. Difficult to treat small epidemics of MRSA furunculosis have been described in families, sports teams and prisons.
Since prolonged use of antibiotics leads to further antimicrobial resistance of bacteria, continuous use of antibiotics to prevent recurrent or chronic folliculitis is not recommended.
Therefore, new strategies in the treatment and prevention of bacterial skin infections are needed. Staphefekt SA.100 is an endolysin, a targeted antibacterial enzyme. Contrary to antibiotics, it kills only S. aureus, including MRSA, leaving the beneficial bacteria intact. And by targeting essential parts of the cell wall of S. aureus, resistance is neither observed nor expected. As an active ingredient in emollients, Staphefekt is therefore suitable for long-term daily use as suppression therapy of S. aureus on the skin
Two cases of S. aureus folliculitis were treated with Staphefekt in an emollient (Gladskin). Both suffered from recurrent infections despite earlier courses of antibiotics and betadine scrub. In one case, the anti-inflammatory drug isotretinoin produced good results with a previous relapse, but had to be discontinued because of severe side effects. Gladskin was used continuously twice a day to reduce S. aureus colonization on the skin and prevent new infections.
A few days after starting daily Gladskin treatment, a clear calming of the skin was reported. Over time, old lesions resolved and no new infections occurred. One patient stopped applying Gladskin after disappearance of the symptoms after 2 weeks, but this led to a relapse. After restarting Gladskin, the symptoms resolved again. Scientific questionnaires evaluating the quality of life (Skindex-28 scale) showed significantly improved scores during therapy. No adverse events were reported.
People will always be challenged with Staphylococcus aureus, as it is often present on our body and in our environment. Throughout several stages, colonization with this bacterium eventually can progress to infection, from innocent local folliculitis to severe sepsis. Antibiotics are not suitable as a continuous preventive measure, as they will induce antimicrobial resistance and unintended disruption of the beneficial skin flora. With Staphefekt, the first targeted antibacterial compound is available for daily use as maintenance therapy, to intervene before colonization can progress and lead to infection.”14
If you have a severe case of folliculitis, please make sure you follow your doctor’s recommendations fully and accurately in order to rapidly restore your health.
(1, 5, 8) WISCONSIN DIVISION OF PUBLIC HEALTH. Department of Health Services. Pseudomonas folliculitis (Pseudomonas aeruginosa) https://www.dhs.wisconsin.gov/publications/p4/p42079.pdf
(2) Department of Dermatology and STD, JIPMER. Dermatitis cruris pustulosa et atrophicans http://www.bioline.org.br/pdf?dv09116
(3) Shimizu-dermatology. Folliculitis. https://www.derm-hokudai.jp/shimizu-dermatology/pdf/24-02.pdf
(4, 7) US National Library of Medicine. National Institute of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798363/
(6, 9,14) Fact Sheet Folliculitis Furunculosis – Micreos Staphefekt SA.100 (Gladskin). http://www.micreos.com/upload/content/file/Fact%20Sheet%20Folliculitis%20Furunculosis%20-%20Micreos%20Staphefekt%20SA.100%20v2.pdf
(10, 12) University of North Carolina Wilmington. https://www.dhs.wisconsin.gov/publications/p4/p42079.pdf
(13) INSTRUCTION SHEET: FOLLICULITIS https://uncw.edu/healthservices/documents/instructionsheet-folliculitis1012.pdf