Understanding Folliculitis: Types, Triggers and How to Prevent It

What is folliculitis?

Folliculitis is a benign skin condition commonly found in many people of all ages. In this condition, the hair follicle becomes infected or inflamed, which can lead to pustule formation. Although the condition is not life-threatening and usually resolves naturally, it may present challenges for individuals with weak immune systems.

What are follicles?

Follicles are the small openings in the skin from which hair emerges. This condition can be superficial or deep and can affect any body part where hair grows, especially where friction is common but mostly found in the neck, scalp, armpits and face. It might resemble an acne or rash and can be acute or long-term.  

Folliculitis causes

The causes of folliculitis mostly include bacterial infection. Folliculitis can also be triggered by fungi, viruses and even non-infectious factors. Here are some of the causative agents for folliculitis.

• Superficial bacterial folliculitis: It is the most common form, usually caused by the bacteria Staphylococcus aureus, including both methicillin-sensitive and methicillin-resistant strains.
• Gram-negative bacterial folliculitis: It is often referred to as ‘hot tub’ folliculitis, caused by Pseudomonas aeruginosa. It typically triggers after exposure to contaminated water in improperly treated swimming pools or hot tubs. Other bacteria like Klebsiella and Enterobacter can also cause this condition, often after long-term use of oral antibiotics.
• Pityrosporum folliculitis: It is a fungal form caused by the Malassezia species, such as Malassezia furfur. It is typically found in adolescents due to increased sebaceous gland activity and is commonly distributed over the shoulders, back and neck. It should be suspected in patients with acne that worsens or does not respond to antibiotics.
• Viral folliculitis: It is most commonly caused by the herpes virus, though it can also be caused by Molluscum contagiosum, which is rarer. Herpes virus folliculitis presents similarly to bacterial folliculitis but with papulovesicles or plaques instead of pustules, and lesions typically appear in groups or clusters.
• Demodex folliculitis: It is caused by the mite Demodex folliculorum. This type is controversial as the Demodex mite is normally present in the pilonidal sebaceous area of the skin, with estimates suggesting that 80–90% of humans may carry this mite.
• Eosinophilic folliculitis: It is predominantly found in individuals with advanced HIV or low CD4 counts, though a non-HIV variation can occur as a rare side effect of chemotherapy. The exact cause is unknown, but it may result from inflammatory disease due to immune dysregulation and possibly an underlying infection. It presents as erythematous and urticarial follicular papules, usually on the scalp, face and neck.
• Pseudofolliculitis barbae: It is a type of non-infectious folliculitis commonly known as razor bumps. This type occurs due to ingrown hairs, often affecting the beard area in men.

Who is at risk of folliculitis?

The exact incidence of folliculitis is not well documented, but certain factors increase the risk of developing the condition. These risk factors include diabetes, obesity, prolonged use of oral antibiotics, immunosuppression and frequent shaving. Gender does not affect the overall incidence. However, certain types, such as Malassezia folliculitis, are more frequently observed in men than in women.

Folliculitis symptoms

Folliculitis presents several symptoms, which vary depending on the severity and type of infection. Common symptoms include:

• Appearance of tiny red bumps or white-headed pimples around hair follicles
• Pus-filled blisters that crust over and break open
• Itching or burning skin
• Painful or tender skin
• Inflamed bumps

Diagnosis

Diagnosing folliculitis involves the following steps:

• Physical examination: Your consultant healthcare provider or dermatologist will examine your skin and ask about your medical history to identify the signs of folliculitis.
• Skin culture test: If the initial examination is inconclusive, a skin culture test may be ordered to determine if the folliculitis is caused by bacteria, fungi or viruses.
• Biopsy: In rare cases, a skin biopsy might be conducted to evaluate the skin tissue and rule out other possible conditions.

Treatment

The treatment of folliculitis depends on its type and severity. Some cases may require intensive care, while others may resolve with minimal treatment.

• Home care: To cure mild folliculitis, here are some home-care tips:
• Use antibacterial cleansers to reduce bacteria on the skin
• Apply warm towels to soothe the skin
• Use anti-itch cream to relieve discomfort

For severe folliculitis:

• Oral antibiotics may be necessary.
• Deep infections, such as boils and carbuncles, may need to be drained by a healthcare provider to remove pus and promote healing.
• For pseudofolliculitis barbae and sycosis barbae:
• Soften hair with hot water before shaving.
• Shave in the direction of hair growth.
• Use shaving gel or cream.
• Shave every other day instead of daily.
• Use an electric razor or hair removal product instead of a traditional razor blade.
• Avoid pulling the skin while shaving.

Prognosis: Folliculitis is generally benign and self-limiting; the outlook and recovery are good. With adequate hygiene and management of any underlying conditions, one can prevent this condition from relapse.

Complications: 

• Cellulitis or abscess formation  
• Permanent scarring that can lead to hair loss
• Drug interactions or side effects from the medications prescribed to treat folliculitis.

Prevention of folliculitis

Preventing folliculitis often involves making changes to your lifestyle and self-care routine to reduce the risk of infection. Here are some tips:

• Keep your skin clean.
• Limit shaving.
• Check the chemical disinfectant levels of hot tubs and heated pools before use, as warmer water can reduce the effectiveness of disinfectants.
• Remove and wash your swimsuit after using a hot tub or pool.
• Wear breathable clothing to prevent sweat from being trapped between your clothes and skin.

Patient education  

In the majority of folliculitis cases, time is the only treatment, as most of them resolve naturally. Antibiotics, antivirals, antifungals or antiparasitic drugs can be prescribed in more severe cases. Patients are advised to maintain proper cleanliness for the affected area as well as apply warm compresses many times each day for up to 15 minutes. In addition, it is also advised not to scratch or shave the affected regions, as this may cause further discomfort and may spread the causative substance.  

Conclusion

Folliculitis is a general condition that can easily be diagnosed by healthcare teams, mostly comprising dermatologists and primary care physicians.  

Proper hygiene is a major factor in preventing recurrence. Also, most cases of folliculitis are self-limiting and resolve naturally with home care. However, it is essential to consult your doctor for worsening symptoms to prevent complications, as severe cases may require medical therapy.