Folliculitis is an infection where one or more hair follicles become inflamed and swollen.
Usually caused by bacteria, folliculitis can also be caused by a virus or fungus which enters the skin through damaged hair follicles causing an infection2,3. The most common bacteria that cause the condition are Staphylococcus aureus (found on the skin), and pseudomonas (found in swimming pools or spas that aren’t well chlorinated). According to Healthdirect Australia, other causes also include parasites, yeasts infections such as tinea and some viruses like herpes. “Skin irritation and ingrown hairs can also cause folliculitis. It sometimes happens after shaving. It is also more common in people who have diabetes, are very overweight, take antibiotics long-term, have low immunity or use oily skincare products2.”
Folliculitis often starts out as a rash or a set of slowly evolving red lumps on the skin. Mayo Clinic describes the following signs and symptoms:
- Clusters of small bumps or pimples around hair follicles
- Pus-filled blisters that break open and crust over
- Itchy, burning skin
- Painful, tender skin
- An inflamed bump3
While general treatment includes maintaining good skin hygiene with non-allergenic and non-comedogenic or oil free topical products to prevent making the condition worse, other treatments depend on the cause of the folliculitis. Dr Laurence Knott gives the following recommendations: 4
- Mild, superficial folliculitis may resolve without treatment.
- Topical antiseptics such as triclosan, chlorhexidine, or povidone-iodine may be used to treat and prevent superficial folliculitis.
- Consider treating nasal carriage of S. aureus with topical Fucidin in those with recurrent folliculitis.
- For deeper folliculitis, topical or oral antibiotics are usually required; preferred agents are flucloxacillin, erythromycin or cephalosporins/mupirocin ointment.
- In severe or recurrent cases, antibiotic therapy may be required for 4 to 6 weeks.
- Other antibiotics may be used depending on culture results and the degree of clinical suspicion of alternative causative organisms – e.g., pseudomonal folliculitis responds to oral ciprofloxacin.
- Fungal infections are usually treated with topical azoles – e.g., clotrimazole or oral ketoconazole.
- Acyclovir or similar agents can be used to treat herpetic folliculitis.4
A common, contagious bacterial infection, impetigo often affects children2.
According to the British Association of Dermatologists: “Impetigo is usually caused by a bacterium called Staphylococcus aureus. These germs pass from person to person by skin-to-skin contact or less often, by bedding, clothing, and towels.” The explained that while the bacteria that cause impetigo can invade normal skin, they more often take advantage of skin that is already damaged by cuts or grazes, head lice or eczema.5
Initially, itchy red skin with a rash of pus-filled blisters forms that break easily and leak, as they heal crusted yellow scabs form. The patches are small at first but slowly get bigger.5,6 “Bacteria are easily spread via contact and new patches can develop at other sites away from the original infection,” the British Association of Dermatologists warned.
“The aim of treatment is to clear the eruption and prevent the spread of the infection to others7,” said Dr Amanda Oakley, Specialist Dermatologist. “Topical antibiotics are as effective as oral antibiotics for treating localised impetigo. The advantage of using topical antibiotics is that are applied only where needed, avoiding systematic adverse effects such as gastrointestinal upset,” she explained. “Fusidic acid and mupirocin have been shown to be equally effective for small, localised patches of impetigo. Antiseptics, such as hydrogen peroxide cream may also be effective7.”
Commonly known as dandruff when a mild case affects the scalp, seborrhoeic dermatitis can also affect the face and centre of the chest.
Although not fully understood, the British Association of Dermatologists explained it’s believed seborrhoeic dermatitis is caused by a yeast called Malassezia that lives on the skin. “Seborrhoeic dermatitis is not usually linked to any underlying illness, but it can be stubborn and severe in people with HIV infection, and it is also common in people with Parkinson’s disease,” they said. “Tiredness and stress can sometimes trigger a flare of seborrheic dermatitis. It is more common in cold than in warm weather, and it is not related to diet8.
Doctors Betty Anne Johnson and Julia Nunley explained that seborrhoeic dermatitis typically affects areas of the skin where sebaceous glands appear in high frequency and are most active. “Common sites of involvement are the hairy areas of the head including the scalp, the scalp margin, eyebrows, moustache, and beard.
“Another characteristic of seborrheic dermatitis is dandruff, characterised by a fine, powdery white scalp. Many patients complain of the scalp itching with dandruff, and because they think that the scale arises from dry skin, they decrease the frequency of shampooing, which allows further scale accumulation. Inflammation then occurs and their symptoms worsen9,” they explained.
Treatment depends on the severity of the seborrhoeic dermatitis. “Hygiene issues play a key role in controlling seborrheic dermatitis,” said Dr Johnson and Dr Nunley. “Patients should be counselled that good hygiene must be a lifelong commitment9.”
If non-prescription products and self-care habits don’t help, Mayo Clinic advises that patients may need one or more of the following treatments:
- Antifungal gels, creams, lotions, foams, or shampoos alternated with another medication.
- Creams, lotions, shampoos, or ointments that control inflammation.
- Antifungal medication you take as a pill.10
“Many cases of seborrheic dermatitis are effectively treated by shampooing daily or every other day with antidandruff shampoos containing 2.5% selenium sulphide or 1-2% pyrithione zinc. Alternatively, ketoconazole shampoo may be used,” Dr Johnson and Dr Nunley explained. “The shampoo should be applied to the scalp and beard areas and left in place for 5-10 minutes before rinsing. A moisturising shampoo may be used afterward to prevent desiccation of the hair. After the disease is under control, the frequency of shampooing with medicated shampoos may be decreased to twice weekly or as needed. Topical terbinafine solution, 1%, has also been shown to be effective in the treatment of scalp seborrhoea9.”
- DFSD Noble, S. L. (1998). ‘Diagnosis and Management of Common Tinea Infections.’ Available from: https://www.aafp.org/afp/1998/0701/p163.html
- Sissons, Claire. Medical News Today (2019) ‘What to know about scalp infections.’ Available from: https://www.medicalnewstoday.com/articles/324132#folliculitis
- Patient Info. ‘Folliculitis’. Available from: https://patient.info/doctor/folliculitis-pro
- British Association of Dermatologists. (2008). ‘Impetigo’. Available from: http://www.bad.org.uk/shared/get-file.ashx?id=211&itemtype=document
- North Dakota Department of Health. (2016). ‘Impetigo’. Available from: https://www.ndhealth.gov/Disease/Documents/faqs/Impetigo.pdf
- Best Practice Advocacy Centre New Zealand. ‘Management of Impetigo’. Available from: https://bpac.org.nz/BPJ/2009/february/docs/bpj19_impetigo_pages_8-11.pdf
- British Association of Dermatologists. (2004). ‘Seborrhoeic Dermatitis’. Available from: https://www.bad.org.uk/pils/seborrhoeic-dermatitis/
- Johnson, B.R & Nunley, J.R. (2000). ‘Treatment of Soborrheic Dermatitis.’ Available from: https://www.aafp.org/afp/2000/0501/p2703.html
- Mayo Clinic. ‘Seborrheic dermatitis’. Available from: https://www.mayoclinic.org/diseases-conditions/seborrheic-dermatitis/diagnosis-treatment/drc-20352714