What Is Folliculitis?

Folliculitis is a skin condition that typically involves inflammation of hair follicles, tiny openings on the skin through which hairs grow. It can cause a rash or tiny bumps called pustules that might resemble acne. It can occur anywhere on the skin, including the scalp.

Folliculitis is common, and anyone can develop it. Though it can be itchy and painful, it's usually benign, or not harmful.

Folliculitis typically resolves on its own and can be treated with topical medications. However, it can lead to complications if you have a weaker immune system.

Types

There are several distinct types of folliculitis, including:

• Superficial bacterial folliculitis: This is the most common type of folliculitis, typically caused by a bacteria called Staphylococcus aureus. This folliculitis usually resolves relatively quickly.
• Demodex folliculitis: This is caused by Demodex mites, which live on most people's skin.
• Eosinophilic pustular folliculitis (EPF): This folliculitis mostly occurs with advanced human immunodeficiency virus (HIV), which is a virus that attacks your immune system. It can also occur if you have a low CD4 count. CD4 is a type of white blood cell: A low count signifies a weakened immune system. EPF is more common in people assigned male at birth.
• Gram-negative bacterial folliculitis: Also known as "hot tub" folliculitis, this is commonly caused by pseudomonas aeruginosa bacteria in contaminated water, like pools and hot tubs. It can also be caused by Klebsiella or Enterobacter bacteria after long-term oral antibiotic use.
• Malassezia folliculitis: Also known as pityrosporum folliculitis, this fungal folliculitis is caused by Malassezia fungi. It's more common in adolescents and people assigned male at birth. It often appears after sun exposure and forms a "cape" of bumps around your neck, back, and shoulders.
  
• Viral folliculitis: This is usually caused by the herpes virus and results in clusters of rash-like spots.

Folliculitis Symptoms

Folliculitis can appear anywhere on the skin or scalp. It may be deep in the hair follicle or more superficial, meaning closer to the surface of the skin.

Symptoms may include:

• Red or inflamed hair follicles
• Infected hair follicles
• Red bumps on the skin
• Pustules on the skin that resemble pimples or acne
• Sores that may crust over as they heal
• Itchiness
• Soreness or tenderness at the site

Causes and Risk Factors

The cause of folliculitis is sometimes unclear. However, it seems to be commonly caused by an infection due to bacteria, viruses, parasites (like the Demodex mite), or fungi. Staphylococcus aureus bacteria is the most common cause.

It can also be caused by irritation or blockage of the follicle, for example, after shaving or tweezing, or friction caused by your skin rubbing against clothing. Inflammation due to ingrown hairs can cause folliculitis, as can medications like lithium and cyclosporine.

Risk Factors

Risk factors for folliculitis include:

• Obesity
• Diabetes
• Frequent shaving, plucking, or waxing
• Long-term use of oral antibiotics
• Wearing tight clothing
• Soaking in a hot tub
• A weak immune system
  

Diagnosis

Because folliculitis is a skin condition, it is typically diagnosed by a dermatologist—a doctor who specializes in skin, hair, and nail health. Most cases of folliculitis are diagnosed by examining your skin and asking questions about your symptoms. Further studies are generally unnecessary.

Diagnosis might require a biopsy to determine the cause of the infection. For example, your healthcare provider might do a biopsy, which is removing a small portion of skin using a scalpel or punch tool.

They might also do a KOH prep. For this test, your healthcare provider will gently scrape off a skin sample and add it to a microscope slide along with a few drops of a potassium hydroxide (KOH) solution. This solution dissolves any non-fungal cells, revealing fungi.

Folliculitis Treatment

Folliculitis is generally benign and will often heal by itself. Practicing good hygiene, like keeping your skin clean and dry, can sometimes help resolve it.

If needed, treatment depends on the cause of the folliculitis. In general, the closer the infection is to the skin's surface, the more easily it's treated. Folliculitis caused by an infectious agent is easier to treat than noninfectious folliculitis, like acne.

For mild or more straightforward cases, your healthcare provider may recommend antimicrobials (medications that prevent the spread of unwanted organisms) such as:

• Topical or oral antibiotics, like benzoyl peroxide, clindamycin, or doxycycline
• Antivirals, like valacyclovir
• Antifungals, like fluconazole or ketoconazole
• Antiparasitics, like ivermectin
• Antibiotic ointments, like erythromycin or bacitracin

Here are common treatments for different types of folliculitis:

• Staphylococcal folliculitis: Most cases of folliculitis caused by bacteria will resolve by themselves within a few days. In more severe cases, your healthcare provider may order a topical antibiotic, such as clindamycin or Bactroban (mupirocin). If these do not work, or if the infection is deeper in the skin or affects a larger skin area, you may need a stronger antibiotic. Antibiotics may be taken by mouth or as a topical ointment.
• Pityrosporum folliculitis: Folliculitis caused by a fungus, such as Pityrosporum folliculitis, might be treated with topical antifungals. However, it may require oral antifungal medicine, like (Sporanox) itraconazole or Diflucan (fluconazole), if deeper under the skin.
• Viral folliculitis: Viral folliculitis is treated based on the virus. For example, if it's caused by the herpes virus, your healthcare provider will treat the skin infection like any other herpes outbreak. This will likely include an oral medication like Zovirax (acyclovir), Famvir (famciclovir), or Valtrex (valacyclovir). If the folliculitis occurs due to underlying HIV, then treating the HIV will usually reduce the folliculitis symptoms.
• Demodex folliculitis: If parasites are responsible for your folliculitis, treatment will likely include an anti-parasitic medicine, anti-parasitic medicine, such as topical or oral ivermectin. In some cases, your healthcare provider may prescribe both topical and oral medicines.

If left untreated, folliculitis can develop into a more serious condition, such as cellulitis. Talk to your healthcare provider if your folliculitis does not resolve on its own. Knowing the underlying cause can help determine the most effective treatment options.

Prevention

You can manage folliculitis symptoms and prevent them from reoccurring. Here are some prevention strategies:

• Practice good hygiene: Keep your skin clean and dry, and talk to your healthcare provider if you have sensitive skin. They may recommend a gentle cleanser based on your skin type. If you are prone to folliculitis in a particular area, use medicated soaps, cleansers, or ointments as your healthcare provider prescribes.
  
• Avoid hair removal: Avoid shaving, plucking, waxing, or friction, in the area for a least three months so the hair can grow back healthy. After that, shave in the direction your hair grows.
• Avoid hot tubs: Avoid them altogether, or at least make sure they're well-maintained.
• Moisturize: Use a drying, antiseptic lotion. If you have another skin condition, such as eczema, apply a non-greasy lotion, like ammonium lactate, to the area, along with any prescription steroid creams your healthcare provider recommends.
• Wear non-irritating clothing: Wear loose clothing, especially if it's hot outside. Avoid friction, rubbing, and fabrics that might irritate your skin, such as tight-fitting clothes, rough fabrics, or Lycra.
  
• Try laser hair removal: If the folliculitis recurs frequently or is resistant to other treatments, laser hair removal treatments may be an option. You may need several of these treatments, and they can be expensive, but they may be an option when nothing else seems to be working. 
  

Living With Folliculitis

Folliculitis is a common skin condition, and it's usually benign. However, it can be physically uncomfortable and, like other skin conditions, might impact self-esteem and overall quality of life.

Talk to your healthcare provider if your symptoms don't resolve on their own. Determining the underlying cause can help you get the most effective treatment. You can also manage your symptoms and prevent future occurrences by being mindful of things like hygiene, hair removal, and clothing choices. Small lifestyle shifts can make a significant difference.