Folliculitis

1 What is Folliculitis?

Folliculitis is a common, benign skin condition in which there is an inflammation of one or more hair follicles.

It is caused either by a bacterial or fungal infection and may appear on the skin of any portion of your body. Certain types of folliculitis are also known as hot tub rash, razor bumps, and barber's itch.

Folliculitis predominantly occurs on your arms, legs, chest, back, buttocks, scalp, and the beard area. It can affect people at any age and is commonly seen in otherwise healthy persons.

Initially, folliculitis appears as small red bumps or white-headed pimples involving a hair follicle - the tiny pocket from which the hair grows. This infection spreads and turns into nonhealing, crusty sores.

The condition is not life-threatening and usually resolves on its own. It can be itchy, sore and embarrassing.

Severe infections may lead to permanent hair loss and scarring. In mild folliculitis, the infection can be cured within a few days with basic self-care measures.

If you have more serious or recurrent folliculitis, you may need to consult a doctor.

2 Symptoms

The signs and symptoms of folliculitis include:

  • Clusters of small red bumps or white-headed pimples that develop around hair follicles
  • Pustules that break open and crust over
  • Red and inflamed skin 
  • Itchy or burning skin rash
  • Tenderness or pain 
  • A large swollen bump or mass

When to see a doctor, consult your doctor if your condition becomes widespread or if the signs and symptoms do not get relieved even after few days. Your doctor will evaluate your condition and prescribe an antibiotic or an antifungal medication to help control the problem.
Types of superficial folliculitis:

Superficial forms of folliculitis include:

Bacterial folliculitis: This is a common type, and is marked by itchy, pus-filled bumps. When it develops on a man's beard area, it is called barber's itch. It happens if hair follicles get infected with a bacteria called Staphylococcus aureus (staph). Staph bacteria are natural inhabitants of our skin, but they can cause problems only if they gain entry into our body through a cut or wound.

Hot tub folliculitis (pseudomonas folliculitis): This type is often caused by the bacteria called Pseudomonas aeruginosa. You may get exposed to these bacteria while bathing in poorly maintained hot tubs and heated pools in which the chlorine and pH levels are not well-regulated. A rash that looks like red, round, itchy bumps develops one to four days after the exposure. The rash may gradually turn into small pus-filled blisters or pustules. The rash appears to be severe in parts of your body directly in contact with a contaminated surface or water, such as the back of your thighs.

Barber's itch (pseudofolliculitis barbae): This is a common condition in which there is inflammation caused by ingrowing hairs on the beard area. It commonly affects black men who shave and is most noticeable on the face and neck region. It appears as clusters of small red bumps that may flare up on repeated shaving. This condition is worse with a curly type of hair. If you shave too closely or below the follicular orifice, the hairs tend to enter into the follicle wall as these grow in a twisted mannaer. The entrapped hair causes inflammation of the hair follicles.

Pityrosporum (pit-ih-ROS-puh-rum) folliculitis: This type is more common among teenagers and adult men. It is due to a yeast infection and results in chronic, red, itchy pustules on your back and chest, and sometimes on the neck, shoulders, upper arms and face.

Types of deep folliculitis:
Deep folliculitis occurs when the entire hair follicle is involved and is of different types such as:

Sycosis barbae: This type is seen in men who have begun to shave. Initially, small pustules may be seen on the upper lip, chin, and jaw, which slowly become more prevalent over some days and weeks as you continue shaving. Severe forms of sycosis barbae may lead to scars.

Gram-negative folliculitis: This type develops if you are on long-term antibiotic treatment for acne. Antibiotics tend to cause an alteration in the normal balance of bacteria in the nasal mucosa. This results in an overgrowth of harmful, gram-negative bacteria that may spread to the skin around the nose and mouth. This causes the development of new, severe acne.

Boils (furuncles) and carbuncles: These are deep infections of hair follicles caused by Staphylococcus bacteria. A boil appears suddenly as a painful pink or red bump with the surrounding skin swollen and red. The bump gets filled with pus, growing larger and more painful before it ruptures and drains. Small boils heal on its own without scarring. A large boil may leave behind a scar as it heals. A carbuncle is a large cluster of several small boils. It usually occurs on the back of the neck, shoulders, back or thighs. A carbuncle is deeper and more severe infection than a single boil. As a result, it develops and heals more slowly, and is likely to cause scar formation.

Eosinophilic (e-o-sin-o-FILL-ik) folliculitis: This type commonly affects people with HIV/AIDS. Symptoms are severe itching and recurrent patches of inflamed, pus-filled bumps on the scalp, face, neck, and upper chest. The rash usually spreads and often leaves behind areas of darker than normal skin (hyperpigmentation) while they heal. The exact cause of eosinophilic folliculitis is unknown, but it may sometimes be caused by the yeast-like fungi involved in pityrosporum folliculitis.

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3 Causes

Folliculitis is caused by an infection of damaged or blocked hair follicle. Various infectious organisms including some viruses and fungi may cause folliculitis, but the bacteria called Staphylococcus aureus is most commonly involved.

The infection may be induced by ingrown hairs, chemical irritants, drugs, and physical irritation caused by shaving. The condition is divided into superficial or deep forms, depending on the degree of involvement of the hair follicle.

Folliculitis commonly occurs on your scalp, and may occur anywhere on your body except the palms, soles, lips, and mucous membranes, where hair follicles are absent. Damaged hair follicles are at a higher risk of infection.

The most common causes of follicle damage are:

  • Friction due to shaving or tight clothing
  • Heat and sweat accumulation caused by wearing of rubber gloves or waders 
  • Certain skin conditions such as dermatitis and acne
  • Injuries to your skin such as from minor scrapes or surgical wounds 
  • Coverings on your skin, such as plastic dressings or adhesive tape

4 Making a Diagnosis

Your doctor can diagnose folliculitis by looking at your skin and reviewing your medical history and symptoms.

Your primary care doctor may refer you to a doctor who specializes in the treatment of skin disorders (dermatologist). To derive the best out of your appointment, it is a good idea to be well-prepared. Here is some information that helps you get ready for the appointment.

What you can do?

  • List down the following information
  • All symptoms you have including those that seem unrelated to your skin condition. 
  • Key personal information including any major stresses or recent life changes. 
  • All your regular medications, vitamins, and supplements.

Questions to ask your doctor. For folliculitis, some basic questions you may ask your doctor include:

  • What may be the most likely cause of my symptoms?
  • What are other possible causes for my symptoms?
  • Do I need any diagnostic tests? 
  • Which is the best treatment for my condition? 
  • How can I best manage my other health conditions together? 
  • What kind of side effects may I expect from treatment?
  • Is there any generic alternative to the medicine you have prescribed? 
  • On what basis is my follow-up visit determined?

What to expect from your doctor. Your doctor may ask you a number of questions such as:

  • For how long have you had this skin infection?
  • Did you have dermatitis in the past?
  • Does your work or a hobby require you to wear rubber gloves or expose your hands to heat and moisture ? 
  • Have you used a hot tub or a heated swimming pool a day or two before you noticed your skin reactions?
  • Are your symptoms continuous or occasional? 
  • Is there any itchiness in your skin ?
  • Is the skin bump painful to touch?
  • Does anything seem to improve or worsen your symptoms?

What can you do in the meantime?

In some cases, folliculitis resolves on its own without medical treatment. Self-care measures such as an application of warm compresses and anti-itch creams may relieve your signs and symptoms.

If the usual treatment methods do not help in clearing up your infection, your doctor may collect a sample of your infected skin using a swab. The sample is examined in a laboratory to determine the cause of the infection. In rare cases, a skin biopsy may be performed to preclude other conditions.

5 Treatment

The treatment plan for folliculitis is devised based on:

  • cause,
  • severity,
  • distribution of the lesions,
  • self-care measures that have been tried already,
  • your preferences for treatment.

In an uncomplicated superficial folliculitis, use of antibacterial soaps and good hand-washing techniques is all that is required.

Medications

  • To control infection: For mild infections, your doctor may prescribe an antibiotic cream mupirocin (Bactroban). Oral antibiotics are not usually prescribed for folliculitis, but in cases of severe or recurrent infection, your doctor may prescribe these.
  • Creams, shampoos or pills to fight fungal infections: Antifungal medications are advised for infections caused by yeast rather than bacteria, such as pityrosporum folliculitis.
  • To reduce inflammation: In conditions of mild eosinophilic folliculitis, your doctor may suggest a steroid cream. In severe conditions, oral corticosteroids may be prescribed. These drugs have serious side effects and should be used with caution for only a brief time. If eosinophilic folliculitis is associated with HIV/AIDS, antiretroviral therapy may improve your symptoms.

Other interventions

  • Minor surgery: In cases of a large boil or a carbuncle, your doctor will perform surgical incision and drainage to remove the pus. Then the area is covered with a sterile gauze if the pus continues to drain.This reduces the pain, accelerates recovery, and decreases scarring.
  • Light therapy with a medicated cream: It is also called photodynamic therapy, and this technique is used in the treatment of folliculitis that has not cleared with other treatments. In a study of consisting of 7 people who had undergone treatment for photodynamic therapy, 6 people showed significant improvement four weeks later.
  • Laser hair removal: It is considered when all the other treatments fail to clear up the infection. This method is a little costly expensive and requires several treatment sessions. It works by permanently decreasing the density of the hair at the site of treatment. Other potential adverse reactions of this therapy include skin discoloration, the formation of scars and blisters.

6 Prevention

Here are a few preventive measure to avoid folliculitis:

  • Avoid shaving your irritated skin for at least a month or until your lesions go away. In order to avoid lesions in the future, avoid shaving too close and replace disposable razors daily. Electrical razors should be periodically soaked in a disinfectant containing 70% alcohol or diluted bleach for at least 1 hour to destroy bacteria or fungi. For men with barber's itch, growing a beard could be a better option if a clean-shaven face is not a must.
  • Avoid snugly-fitting clothes to reduce friction between your skin and clothing.
  • Maintain good personal hygiene by bathing daily, hand washing, and keeping your fingernails short and clean.
  • Dry out your rubber gloves between uses: If you wear rubber gloves regularly after each use turn them inside out, wash with soap and water, and dry them thoroughly.
  • Wash your towels, washcloths, and sheets frequently and avoid sharing them with other family members.
  • Use only clean hot tubs and heated pools: Hot tubs should be regularly cleaned and chlorinated.

Adopt habits such as:

  • Wash your skin with warm water and a mild facial cleanser before shaving
  • Use a washcloth or cleansing pad in a gentle circular motion 
  • Apply a lubricating shaving cream or gel for 5-10 minutes before shaving to soften your hair 
  • Apply a moisturizing lotion after you shave
  • Generally, men with barber's itch have been advised to shave in the direction of hair growth.

7 Lifestyle and Coping

There are different ways to adapt your lifestyle in coping with folliculitis.

Mild cases of folliculitis respond well to home care. Here are some self-care tips that may help you relieve discomfort, speed up healing, and prevent spread of infection:

  • Application of a warm, moist washcloth or compress: Doing this as many times in a day relieves discomfort and helps in the drainage of the pus if needed. Moisten the compress with a saltwater solution (1 teaspoon of table salt in 2 cups of water).
  • Application of over-the-counter antibiotics: You can apply various nonprescription infection-fighting gels, creams and washes to get some relief.
  • Apply soothing lotions: An oatmeal lotion or an over-the-counter hydrocortisone cream may relieve itchy skin.
  • Keep your skin clean: Wash the infected skin twice in a day gently using an antibacterial soap. Wipe with a clean washcloth and towel each time and do not share your towels or washcloths. Use hot, soapy water to wash clothing that has touched the affected area.
  • Protect the skin: If possible, you can avoid shaving. If you have to shave, try using an electric razor. After shaving, rinse your skin with warm water and apply a moisturizing lotion.

8 Risks and Complications

There are several risks and complications associated with folliculitis.

Folliculitis may develop in any person. But certain groups of people may be more susceptible to develop folliculitis. These include people with:

  • A medical condition that reduces their resistance to infection, such as diabetes, hepatitis, cancer, chronic leukemia and HIV/AIDS
  • Acne or dermatitis
  • Past damage to skin, for instance, an injury or surgery
  • Regular medications such as steroid creams or long-term antibiotic therapy for acne
  • Obesity
  • Necessity to wear clothing that entraps heat and sweat, such as rubber gloves or high boots
  • Habit of using hot tub that is not maintained properly

Although uncommon, there are a few potential complications of deep, persistent folliculitis. These includes:

  • Cellulitis
  • Recurrent or spreading infection
  • Large, itchy patches of infected skin (plaques)
  • Boils under the skin (furunculosis)
  • Permanent damage to the skin such as scarring or dark spots
  • Destruction of hair follicles and permanent hair loss
  • Sinus tract formation
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