Facial bacterial infections: Folliculitis Ana Cristina Laureano MD, Robert A. Schwartz MD, MPH, Philip J. Cohen MD PII: DOI: Reference:
S0738-081X(14)00043-1 doi: 10.1016/j.clindermatol.2014.02.009 CID 6826
To appear in:
Clinics in Dermatology
Please cite this article as: Laureano Ana Cristina, Schwartz Robert A., Cohen Philip J., Facial bacterial infections: Folliculitis, Clinics in Dermatology (2014), doi: 10.1016/j.clindermatol.2014.02.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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ACCEPTED MANUSCRIPT
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FACIAL BACTERIAL INFECTIONS: Folliculitis
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Ana Cristina Laureano MD, Robert A. Schwartz MD, MPH, Philip J. Cohen MD
Dermatology, New Jersey Medical School, Newark, New Jersey.
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Address correspondence to Robert A. Schwartz, MD, MPH, Dermatology, Rutgers Health Sciences Campus at Newark (formerly UMDNJ- New Jersey Medical
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ABSTRACT
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School), 185 South Orange Avenue, Room H-576, Newark, New Jersey 07103-2714.
Facial bacterial infections are most commonly caused by infections of hair follicles. Wherever pilosebaceous units are found, folliculitis can occur, and the most common bacterial cause of folliculitis is Staphylococcus aureus. We review different forms of facial folliculitis, distinguishing bacterial forms from other infectious and noninfectious mimickers. We distinguish folliculitis from pseudofolliculitis and perifolliculitis. Clinical features, etiology, pathology, and management options are discussed.
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT
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INTRODUCTION
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Folliculitis properly refers to inflammation of the hair follicle. This may occur from a number of etiologies, infectious and noninfectious. Infectious folliculitis may
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be bacterial or nonbacterial (viral, fungal, parasitic). Infectious folliculitis may be superficial or deep, with significant differences in clinical presentation and treatment.
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When noninfectious, folliculitis may occur secondary to follicular trauma or
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occlusion.
In general, the superficial folliculitis is more easily treated than deep folliculitis,
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noninfectious causes.
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and infectious folliculitis is generally more amenable to treatment than folliculitis of
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CLINICAL FEATURES
Facial bacterial skin infections are common, and the most common infection of the face is bacterial folliculitis caused by Staphylococcus aureas. Facial bacterial folliculitis manifests as clusters of multiple small, raised, pruritic, erythematous papules usually less than 5 mm in diameter. Pustules may be present. The onset is usually acute.1 Folliculitis may be superficial or deep, depending upon which part of the hair follicle is affected.
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT Superficial folliculitis typically consists of multiple small papules and pustules on an erythematous base, each papule or pustule pierced by a central hair. These
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superficial lesions usually heal without scarring. Deep folliculitis is commonly
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manifests as plaques and nodules. Pustules, when present, usually overlie erythema and induration. Commonly, deep folliculitis is painful and heals with scarring.2
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Sometimes, a patterned area of folliculitis arises in areas that were shaved or occluded. Any hair-bearing site can be affected, but the sites most often involved are
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the face and scalp. Superficial infections can evolve into deep infections.
MA
A common variant of superficial folliculitis is impetigo of Bockhart (Figure 1). Poor hygiene and occlusion of the skin have been implicated as promoting factors,
ED
with the causative bacterial culprit being Staphylococcus aureus. Unlike streptococcal infections, which spread as they dissect through collagen, follicular
PT
infections secondary to S. aureus tend to remain relatively localized as pustules rather
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than vesiculobullae. Clinically, one encounters a domed yellow pustule, sometimes with a narrow red areola. Using a hand lens, one may identify a small hair piercing
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each pustule. The pustules develop in crops and heal in 7-10 days with or without treatment but they may also become chronic. In older children and adults, the infection may extend more deeply as furuncles, and, in some cases, chronic Bockhart's impetigo may merge imperceptibly with folliculitis decalvans and related processes.3 Among acne patients, the causative organisms for superficial facial folliculitis tend to be gram negative. Approximately 4% of patients with acne vulgaris treated with systemic antibiotics − most commonly tetracycline − develop the sudden onset of a gram-negative bacterial superficial folliculitis.4,5,6 This type of folliculitis Facial Bacterial Infections
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ACCEPTED MANUSCRIPT develops when normal skin flora (e.g., Staphylococcus epidermidis) are replaced or displaced by gram-negative organisms (Enterobacter, Klebsiella, Escherichia,
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small pustules that spread to the cheeks and chin.
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Serratia, and Proteus). The lesions usually arise in the perinasal region as multiple
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When involvement of the follicle is more extensive and deep, a follicularcentered dermal furuncle or boil results. When the deep follicular infection involves
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the beard areas or the chin, it is known as folliculitis barbae vulgaris, a condition which tends to be chronic. The erythematous papules and pustules that form around
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the coarse hairs in the beard range from asymptomatic to painful and tender.7
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Commonly, the causative organism is a species of Staphylococcus or Propionibacter. Nasal furunculosis is a deep infection of the hair follicle within the nasal
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vestibule. The tip of the nose becomes red and very painful. A nodule may be
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palpated or even visualized in the nasal vestibule (Figure 2). The likely causative
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bacteria is Staphylococcus aureus. PATHOLOGY
Acute bacterial folliculitis usually shows an infiltrate of neutrophils infiltrating around a hair follicle. In superficial folliculitis, the neutrophils are confined to the infundibulum; in deep folliculitis, neutrophils infiltrate the deeper portion of the follicle and surrounding dermis.8 Older lesions show chronic granulomatous inflammation with giant cells containing keratin and fragmented hair.9 While suppurative folliculitiis often heals without clinical residue, some longstanding
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT conditions may progress from suppuration to the formation of granulomas or fibrosis
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with evident clinical scarring.
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Staphylococcal folliculitis commonly shows a subcorneal abcess with abscess of the follicular infundibulum and infection of the more superficial aspects of the
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surrounding dermis. Factors implicated in increasing the risk of staphylococcal folliculitis include immunosuppression (e.g., HIV),10 and reduction in white blood
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cell production (e.g., isotretinoin therapy).11 Similarly, other immunosuppressive increase the risk of folliculitis.
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medications (e.g., corticosteroids) or immunosuppressive conditions (e.g., diagetes),
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Staphylococci are responsible for many cases of facial folliculitis but in some forms, the role of bacteria remains unclear. Folliculitis barbae, for example, is a deep
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folliculitis occurring in beard areas. S. aureus can often be isolated from the noses of
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these patients;12 however, Staphylococcus usually penetrates no deeper than the follicular ostia, and so this is considered a noninfectious form of folliculitis (see
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below).
DIFFERENTIAL DIAGNOSIS Bacterial folliculitis must be differentiated from other infectious causes of facial folliculitis: viruses (e.g., Herpes simplex, Herpes varicella-zoster, Molluscum contagiosum), fungi (e.g., Candida, Pityrosporum), and parasites (e.g., Demodex folliculorum).
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT Noninfectious folliculitis is most commonly caused by follicular trauma or follicular occlusion. Follicles may be traumatized during shaving or during hair
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removal with tweezers. Folliculitis secondary to follicular occlusion is seen with the
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use of adhesive dressings, with topically-applied oils (suntan oils, hair oils, and bath oils) and with occupational exposure to solvents and tars.13 In these cases, the lesions
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commonly present as small, follicular papules or pinhead pustules over the face,
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neck, arms, thighs, or buttocks. They are rarely painful. The pustule is often sterile. Acne vulgaris is also a kind of noninfectious folliculitis induced by follicular
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occlusion. Abnormal keratinization results in the formation of a keratin plug, which obstructs outflow of sebum from the follicle. Sebum fills the follicle, providing
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abundant substrate for Propionobacter acnes to metabolize sebum into pro-
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inflammatory free fatty acids.
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Eosinophilic folliculitis is noninfectious and of unclear etiology. Clinically, eosinphilic folliculitis manifests as intensely pruritic pustules. Among Japanese
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males, eosinophilic pustular folliculitis (Ofuji disease) arises at an average age of 30 years. The lesions initially begin as discrete papules and pustules on the face, back, and extensor surfaces of the arms. These lesions eventually coalesce to form circinate plaques composed of a peripheral rim of pustules and central clearing within the plaque. The lesions reappear cyclically and spontaneously resolve in 7-10 days. Peripheral eosinophilia is often present.14 In the eosinophilic folliculitis of AIDS or other immunosuppression, the pruritic papules typically appear over the face, scalp, and upper trunk of adult males with a CD4+ count of less than 300 cells/μL.15 Facial Bacterial Infections
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Pseudofolliculitis barbae is clearly associated with shaving and tightly kinked
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(curled) hair. The patient complains of minor tenderness or pain, pruritus, and
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cosmetic embarrassment from erythematous papules or pustules over the beard area – most commonly over the submandibular neck in men who shave. The papules and
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pustules may develop into persistent hypertrophic, keloidal-appearing scars.
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Pseudofolliculitis barbae develops when tightly kinked hair is closely shaved and curves back into the skin, penetrating to the dermis and inducing a foreign body
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reaction (Figure 3).16 Properly, this condition is a perifolliculitis, rather than a folliculitis, since the hair shaft re-enters the skin adjacent to its exit point (the
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follicle). Unsheathed hair (keratin), highly immunogenic to the dermis, incites inflammation, causing a chronic foreign body granulomatous reaction with scarring.
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When pseudofolliculitis barbae is pustular, there is commonly a secondary
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superinfection with S. epidermidis.16
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Tightly kinked hairs also play a role in the pathogenesis of folliculitis keloidalis nuchae, in which small follicular papules or pustules develop on the nape of the neck and often extend to the posterior scalp. These lesions give rise to hard, pruritic papules, which may coalesce into large, firm, keloidal-appearing plaques and nodules (Figures 3 and 4). Histologically, they resemble scar tissue, rather than true keloids.17 TREATMENT When managing folliculitis, we consider etiology, severity, and anatomic distribution. Many forms of folliculitis respond to the topical application of warm Facial Bacterial Infections
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ACCEPTED MANUSCRIPT normal saline compresses (1 teaspoon of table salt in two cups of tap water), followed by application of bacitracin or erythromycin ointment and sterile absorbent gauze
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dressings.18 For mild cases caused by S. aureus, a 7-to-10-day course of oral
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erythromycin may be used (250 to 500 mg qid for adults and 30 to 50 mg/kg/day in equally divided doses every 6 hours for children). When the infection recurs, the
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search for a bacterial reservoir (e.g., nose, teeth, tonsils) may be important. Triple antibiotic ointment (bacitracin/polysporin/neomycin) has been shown effective in
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preventing streptococcal pyoderma in children at increased risk for such infections.19 The topical antibiotic mupirocin (Bactroban) has been shown to reduce nasal carriage
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of S. Aureus and may aid in the treatment of chronic S. Aureus folliculitis.
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Recurrent deep folliculitis (boils or carbuncles), typically caused by Staphylococcus, is more difficult to treat. For lesions that are conical with a pustular
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head, initial treatment consists of incision and drainage. After local application of
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heat, a small (2-4 mm) incision (to minimize scarring) is made with a #11 blade. Boils or carbuncles may require several months of treatment with oral antibiotics.
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Dicloxacillin or a cephalosporin are first line therapies, given the growing prevalence of resistance to penicillin. With methicillin-resistant organisms more common, clindamycin, trimethoprim-sulfamethoxazole, tetracyclines (minocycline, doxycycline), erythromycin, or linezolid may be used. For gram-negative folliculitis complicating acne treatment, after discontinuing the implicated antibiotic, administer ampicillin or trimethoprim-sulfamethoxazole for an additional 10 to 14 days after the lesions have resolved.4
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT In most cases, growing a beard in pseudofolliculitis barbae is curative. When the patient insists upon shaving closely, topical clindamycin lotion helps reduce
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secondary infections. Topical retinoic acid or topical antibiotic-with-steroid helps
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control the condition.20 Surgical depilation is an option when other therapy has
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failed.21
Folliculitis barbae requires the basic approach comprised of antibacterial soap,
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local warm saline compresses, and topical antibiotics, while more extensive cases
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may require systemic antibiotics.
For folliculitis keloidalis nuchae, topical clindamycin combined with
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fluocinolone acetonide gel is useful. Radiotherapy has not produced impressive results for the earlier inflammatory stage or the late fibrous plaque-stage of this
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disorder; however, intralesional corticosteroids or surgical removal of sub-follicular
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diseased tissue may be helpful in advanced cases.22
REFERENCES 1.
Müller H, Eisendle K, Zelger B. Chronic recurrent follicular papules and plaques on the face. Clin Exp Dermatol. 2010; 35(1):99-100.
2.
Eley CD, Gan VN. Picture of the month. Folliculitis, furunculosis, and carbuncles. Arch Pediatr Adolesc Med. 1997;151(6):625-6
3.
Geria AN, Schwartz RA. Impetigo update: new challenges in the era of methicillin resistance. Cutis. 2010;85(2):65-70
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT Leyden JJ, Marples RR, Mills OH Jr., et al. Gram-negative folliculitis: a complication of antibiotic therapy in acne vulgaris. Br J Dermatol 1973; 88: 533-8.
5.
Mostafa WZ. Citrobacter Freundii in gram-negative folliculitis. J Am Acad Dermatol 1989; 20:504-5.
6.
Leyden JJ, et al: Pseudomonas aeruginosa gram-negative folliculitis. Arch Dermatol 1979; 115:1203-4.
7.
James, William D; Berger, Timothy G.; et al. Andrews' Diseases of the Skin: Clinical Dermatology. Saunders Elsevier, 2006.
8.
Janniger CK, Schwartz RA, Szepietowski JC, Reich A. Intertrigo and common secondary skin infections. Am Fam Physician 2005;72:833-8.
9.
Celestin R, Brown J, Kihiczak G, Schwartz RA. Erysipelas: a common potentially dangerous infection. Acta Dermatovenerol Alp Panonica Adriat 2007;16: 123-8.
10.
Lee RE, Schwartz RA. Pediatric molluscum contagiosum: reflections on the last challenging poxvirus infection, Part 1. Cutis 2010;86: 230-6.
11.
Lee RE, Schwartz RA. Pediatric molluscum contagiosum: reflections on the last challenging poxvirus infection, Part 2. Cutis 2010;86: 287-92.
12.
Lin RL, Szepietowski JC, Schwartz RA. Tinea faciei: an often deceptive facial eruption. Int J Dermatol 2004;43: 437-40.
13.
Alchorne Ade O, Alchorne MM, Silva MM. Occupational dermatosis. An Bras Dermatol. 2010;85(2):137-45
14.
Nervi SJ, Schwartz RA, Dmochowski M. Eosinophilic pustular folliculitis: a 40 year retrospect. J Am Acad Dermatol. 2006;55(2):285-9
15.
Zancanaro PC, McGirt LY, Mamelak AJ, Nguyen RH, Martins CR. Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience. J Am Acad Dermatol. 2006;54(4):581-8.
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4.
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ACCEPTED MANUSCRIPT Quarles FN, Brody H, Johnson BA, Badreshia S, Vause SE, Brauner G, Breadon JY, Swinehart J, Callendar V. Pseudofolliculitis barbae. Dermatol Ther. 2007;20(3):133-6.
18.
Provost TT, Farmer ER. Current Therapy in Dermatology-2. B.C. Decker, Philadelphia, 1988, p. 211.
17.
Kelly AP. Pseudofolliculitis barbae and acne keloidalis nuchae. Dermatol Clin. 2003;21(4):645-53
19.
Maddox JS, Ware JC, Dillon HC. The Natural History of Streptococcal Skin Infection: Prevention with topical antibiotics. J Am Acad Dermatol 1985;13:207-12
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SC
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16.
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20. Kligman AM, Mills OH. Pseudofolliculitis of the beard and topically applied tretinoin. Arch Dermatol 1973;107: 551.
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21. Hage JJ, Bouman FG. Surgical depilation for the treatment of pseudofollicuitis or local hirsuitism of the face: experience in the first 40 patients. Plast Reconstr Surg 1991;88: 446-51.
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22. Vasily DB, Breen PC, Miller OF. Acne keloidalis nuchae: Report and treatment of a severe case. J Dermatol Surg Oncol 1979;5: 228-30.
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ACCEPTED MANUSCRIPT FIGURES
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Fig. 1 Impetigo
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Fig. 2
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Fig. 3
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Fig 4
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S0738-081X(14)00043-1 doi: 10.1016/j.clindermatol.2014.02.009 CID 6826
To appear in:
Clinics in Dermatology
Please cite this article as: Laureano Ana Cristina, Schwartz Robert A., Cohen Philip J., Facial bacterial infections: Folliculitis, Clinics in Dermatology (2014), doi: 10.1016/j.clindermatol.2014.02.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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ACCEPTED MANUSCRIPT
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FACIAL BACTERIAL INFECTIONS: Folliculitis
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Ana Cristina Laureano MD, Robert A. Schwartz MD, MPH, Philip J. Cohen MD
Dermatology, New Jersey Medical School, Newark, New Jersey.
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Address correspondence to Robert A. Schwartz, MD, MPH, Dermatology, Rutgers Health Sciences Campus at Newark (formerly UMDNJ- New Jersey Medical
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ABSTRACT
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School), 185 South Orange Avenue, Room H-576, Newark, New Jersey 07103-2714.
Facial bacterial infections are most commonly caused by infections of hair follicles. Wherever pilosebaceous units are found, folliculitis can occur, and the most common bacterial cause of folliculitis is Staphylococcus aureus. We review different forms of facial folliculitis, distinguishing bacterial forms from other infectious and noninfectious mimickers. We distinguish folliculitis from pseudofolliculitis and perifolliculitis. Clinical features, etiology, pathology, and management options are discussed.
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT
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INTRODUCTION
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Folliculitis properly refers to inflammation of the hair follicle. This may occur from a number of etiologies, infectious and noninfectious. Infectious folliculitis may
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be bacterial or nonbacterial (viral, fungal, parasitic). Infectious folliculitis may be superficial or deep, with significant differences in clinical presentation and treatment.
MA
When noninfectious, folliculitis may occur secondary to follicular trauma or
ED
occlusion.
In general, the superficial folliculitis is more easily treated than deep folliculitis,
CE
noninfectious causes.
PT
and infectious folliculitis is generally more amenable to treatment than folliculitis of
AC
CLINICAL FEATURES
Facial bacterial skin infections are common, and the most common infection of the face is bacterial folliculitis caused by Staphylococcus aureas. Facial bacterial folliculitis manifests as clusters of multiple small, raised, pruritic, erythematous papules usually less than 5 mm in diameter. Pustules may be present. The onset is usually acute.1 Folliculitis may be superficial or deep, depending upon which part of the hair follicle is affected.
Facial Bacterial Infections
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ACCEPTED MANUSCRIPT Superficial folliculitis typically consists of multiple small papules and pustules on an erythematous base, each papule or pustule pierced by a central hair. These
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superficial lesions usually heal without scarring. Deep folliculitis is commonly
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manifests as plaques and nodules. Pustules, when present, usually overlie erythema and induration. Commonly, deep folliculitis is painful and heals with scarring.2
SC
Sometimes, a patterned area of folliculitis arises in areas that were shaved or occluded. Any hair-bearing site can be affected, but the sites most often involved are
NU
the face and scalp. Superficial infections can evolve into deep infections.
MA
A common variant of superficial folliculitis is impetigo of Bockhart (Figure 1). Poor hygiene and occlusion of the skin have been implicated as promoting factors,
ED
with the causative bacterial culprit being Staphylococcus aureus. Unlike streptococcal infections, which spread as they dissect through collagen, follicular
PT
infections secondary to S. aureus tend to remain relatively localized as pustules rather
CE
than vesiculobullae. Clinically, one encounters a domed yellow pustule, sometimes with a narrow red areola. Using a hand lens, one may identify a small hair piercing
AC
each pustule. The pustules develop in crops and heal in 7-10 days with or without treatment but they may also become chronic. In older children and adults, the infection may extend more deeply as furuncles, and, in some cases, chronic Bockhart's impetigo may merge imperceptibly with folliculitis decalvans and related processes.3 Among acne patients, the causative organisms for superficial facial folliculitis tend to be gram negative. Approximately 4% of patients with acne vulgaris treated with systemic antibiotics − most commonly tetracycline − develop the sudden onset of a gram-negative bacterial superficial folliculitis.4,5,6 This type of folliculitis Facial Bacterial Infections
Page 3
ACCEPTED MANUSCRIPT develops when normal skin flora (e.g., Staphylococcus epidermidis) are replaced or displaced by gram-negative organisms (Enterobacter, Klebsiella, Escherichia,
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small pustules that spread to the cheeks and chin.
T
Serratia, and Proteus). The lesions usually arise in the perinasal region as multiple
SC
When involvement of the follicle is more extensive and deep, a follicularcentered dermal furuncle or boil results. When the deep follicular infection involves
NU
the beard areas or the chin, it is known as folliculitis barbae vulgaris, a condition which tends to be chronic. The erythematous papules and pustules that form around
MA
the coarse hairs in the beard range from asymptomatic to painful and tender.7
ED
Commonly, the causative organism is a species of Staphylococcus or Propionibacter. Nasal furunculosis is a deep infection of the hair follicle within the nasal
PT
vestibule. The tip of the nose becomes red and very painful. A nodule may be
CE
palpated or even visualized in the nasal vestibule (Figure 2). The likely causative
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bacteria is Staphylococcus aureus. PATHOLOGY
Acute bacterial folliculitis usually shows an infiltrate of neutrophils infiltrating around a hair follicle. In superficial folliculitis, the neutrophils are confined to the infundibulum; in deep folliculitis, neutrophils infiltrate the deeper portion of the follicle and surrounding dermis.8 Older lesions show chronic granulomatous inflammation with giant cells containing keratin and fragmented hair.9 While suppurative folliculitiis often heals without clinical residue, some longstanding
Facial Bacterial Infections
Page 4
ACCEPTED MANUSCRIPT conditions may progress from suppuration to the formation of granulomas or fibrosis
T
with evident clinical scarring.
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Staphylococcal folliculitis commonly shows a subcorneal abcess with abscess of the follicular infundibulum and infection of the more superficial aspects of the
SC
surrounding dermis. Factors implicated in increasing the risk of staphylococcal folliculitis include immunosuppression (e.g., HIV),10 and reduction in white blood
NU
cell production (e.g., isotretinoin therapy).11 Similarly, other immunosuppressive increase the risk of folliculitis.
MA
medications (e.g., corticosteroids) or immunosuppressive conditions (e.g., diagetes),
ED
Staphylococci are responsible for many cases of facial folliculitis but in some forms, the role of bacteria remains unclear. Folliculitis barbae, for example, is a deep
PT
folliculitis occurring in beard areas. S. aureus can often be isolated from the noses of
CE
these patients;12 however, Staphylococcus usually penetrates no deeper than the follicular ostia, and so this is considered a noninfectious form of folliculitis (see
AC
below).
DIFFERENTIAL DIAGNOSIS Bacterial folliculitis must be differentiated from other infectious causes of facial folliculitis: viruses (e.g., Herpes simplex, Herpes varicella-zoster, Molluscum contagiosum), fungi (e.g., Candida, Pityrosporum), and parasites (e.g., Demodex folliculorum).
Facial Bacterial Infections
Page 5
ACCEPTED MANUSCRIPT Noninfectious folliculitis is most commonly caused by follicular trauma or follicular occlusion. Follicles may be traumatized during shaving or during hair
T
removal with tweezers. Folliculitis secondary to follicular occlusion is seen with the
RI P
use of adhesive dressings, with topically-applied oils (suntan oils, hair oils, and bath oils) and with occupational exposure to solvents and tars.13 In these cases, the lesions
SC
commonly present as small, follicular papules or pinhead pustules over the face,
NU
neck, arms, thighs, or buttocks. They are rarely painful. The pustule is often sterile. Acne vulgaris is also a kind of noninfectious folliculitis induced by follicular
MA
occlusion. Abnormal keratinization results in the formation of a keratin plug, which obstructs outflow of sebum from the follicle. Sebum fills the follicle, providing
ED
abundant substrate for Propionobacter acnes to metabolize sebum into pro-
PT
inflammatory free fatty acids.
CE
Eosinophilic folliculitis is noninfectious and of unclear etiology. Clinically, eosinphilic folliculitis manifests as intensely pruritic pustules. Among Japanese
AC
males, eosinophilic pustular folliculitis (Ofuji disease) arises at an average age of 30 years. The lesions initially begin as discrete papules and pustules on the face, back, and extensor surfaces of the arms. These lesions eventually coalesce to form circinate plaques composed of a peripheral rim of pustules and central clearing within the plaque. The lesions reappear cyclically and spontaneously resolve in 7-10 days. Peripheral eosinophilia is often present.14 In the eosinophilic folliculitis of AIDS or other immunosuppression, the pruritic papules typically appear over the face, scalp, and upper trunk of adult males with a CD4+ count of less than 300 cells/μL.15 Facial Bacterial Infections
Page 6
ACCEPTED MANUSCRIPT
Pseudofolliculitis barbae is clearly associated with shaving and tightly kinked
T
(curled) hair. The patient complains of minor tenderness or pain, pruritus, and
RI P
cosmetic embarrassment from erythematous papules or pustules over the beard area – most commonly over the submandibular neck in men who shave. The papules and
SC
pustules may develop into persistent hypertrophic, keloidal-appearing scars.
NU
Pseudofolliculitis barbae develops when tightly kinked hair is closely shaved and curves back into the skin, penetrating to the dermis and inducing a foreign body
MA
reaction (Figure 3).16 Properly, this condition is a perifolliculitis, rather than a folliculitis, since the hair shaft re-enters the skin adjacent to its exit point (the
ED
follicle). Unsheathed hair (keratin), highly immunogenic to the dermis, incites inflammation, causing a chronic foreign body granulomatous reaction with scarring.
PT
When pseudofolliculitis barbae is pustular, there is commonly a secondary
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superinfection with S. epidermidis.16
AC
Tightly kinked hairs also play a role in the pathogenesis of folliculitis keloidalis nuchae, in which small follicular papules or pustules develop on the nape of the neck and often extend to the posterior scalp. These lesions give rise to hard, pruritic papules, which may coalesce into large, firm, keloidal-appearing plaques and nodules (Figures 3 and 4). Histologically, they resemble scar tissue, rather than true keloids.17 TREATMENT When managing folliculitis, we consider etiology, severity, and anatomic distribution. Many forms of folliculitis respond to the topical application of warm Facial Bacterial Infections
Page 7
ACCEPTED MANUSCRIPT normal saline compresses (1 teaspoon of table salt in two cups of tap water), followed by application of bacitracin or erythromycin ointment and sterile absorbent gauze
T
dressings.18 For mild cases caused by S. aureus, a 7-to-10-day course of oral
RI P
erythromycin may be used (250 to 500 mg qid for adults and 30 to 50 mg/kg/day in equally divided doses every 6 hours for children). When the infection recurs, the
SC
search for a bacterial reservoir (e.g., nose, teeth, tonsils) may be important. Triple antibiotic ointment (bacitracin/polysporin/neomycin) has been shown effective in
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preventing streptococcal pyoderma in children at increased risk for such infections.19 The topical antibiotic mupirocin (Bactroban) has been shown to reduce nasal carriage
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of S. Aureus and may aid in the treatment of chronic S. Aureus folliculitis.
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Recurrent deep folliculitis (boils or carbuncles), typically caused by Staphylococcus, is more difficult to treat. For lesions that are conical with a pustular
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head, initial treatment consists of incision and drainage. After local application of
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heat, a small (2-4 mm) incision (to minimize scarring) is made with a #11 blade. Boils or carbuncles may require several months of treatment with oral antibiotics.
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Dicloxacillin or a cephalosporin are first line therapies, given the growing prevalence of resistance to penicillin. With methicillin-resistant organisms more common, clindamycin, trimethoprim-sulfamethoxazole, tetracyclines (minocycline, doxycycline), erythromycin, or linezolid may be used. For gram-negative folliculitis complicating acne treatment, after discontinuing the implicated antibiotic, administer ampicillin or trimethoprim-sulfamethoxazole for an additional 10 to 14 days after the lesions have resolved.4
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ACCEPTED MANUSCRIPT In most cases, growing a beard in pseudofolliculitis barbae is curative. When the patient insists upon shaving closely, topical clindamycin lotion helps reduce
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secondary infections. Topical retinoic acid or topical antibiotic-with-steroid helps
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control the condition.20 Surgical depilation is an option when other therapy has
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failed.21
Folliculitis barbae requires the basic approach comprised of antibacterial soap,
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local warm saline compresses, and topical antibiotics, while more extensive cases
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may require systemic antibiotics.
For folliculitis keloidalis nuchae, topical clindamycin combined with
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fluocinolone acetonide gel is useful. Radiotherapy has not produced impressive results for the earlier inflammatory stage or the late fibrous plaque-stage of this
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disorder; however, intralesional corticosteroids or surgical removal of sub-follicular
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diseased tissue may be helpful in advanced cases.22
REFERENCES 1.
Müller H, Eisendle K, Zelger B. Chronic recurrent follicular papules and plaques on the face. Clin Exp Dermatol. 2010; 35(1):99-100.
2.
Eley CD, Gan VN. Picture of the month. Folliculitis, furunculosis, and carbuncles. Arch Pediatr Adolesc Med. 1997;151(6):625-6
3.
Geria AN, Schwartz RA. Impetigo update: new challenges in the era of methicillin resistance. Cutis. 2010;85(2):65-70
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ACCEPTED MANUSCRIPT Leyden JJ, Marples RR, Mills OH Jr., et al. Gram-negative folliculitis: a complication of antibiotic therapy in acne vulgaris. Br J Dermatol 1973; 88: 533-8.
5.
Mostafa WZ. Citrobacter Freundii in gram-negative folliculitis. J Am Acad Dermatol 1989; 20:504-5.
6.
Leyden JJ, et al: Pseudomonas aeruginosa gram-negative folliculitis. Arch Dermatol 1979; 115:1203-4.
7.
James, William D; Berger, Timothy G.; et al. Andrews' Diseases of the Skin: Clinical Dermatology. Saunders Elsevier, 2006.
8.
Janniger CK, Schwartz RA, Szepietowski JC, Reich A. Intertrigo and common secondary skin infections. Am Fam Physician 2005;72:833-8.
9.
Celestin R, Brown J, Kihiczak G, Schwartz RA. Erysipelas: a common potentially dangerous infection. Acta Dermatovenerol Alp Panonica Adriat 2007;16: 123-8.
10.
Lee RE, Schwartz RA. Pediatric molluscum contagiosum: reflections on the last challenging poxvirus infection, Part 1. Cutis 2010;86: 230-6.
11.
Lee RE, Schwartz RA. Pediatric molluscum contagiosum: reflections on the last challenging poxvirus infection, Part 2. Cutis 2010;86: 287-92.
12.
Lin RL, Szepietowski JC, Schwartz RA. Tinea faciei: an often deceptive facial eruption. Int J Dermatol 2004;43: 437-40.
13.
Alchorne Ade O, Alchorne MM, Silva MM. Occupational dermatosis. An Bras Dermatol. 2010;85(2):137-45
14.
Nervi SJ, Schwartz RA, Dmochowski M. Eosinophilic pustular folliculitis: a 40 year retrospect. J Am Acad Dermatol. 2006;55(2):285-9
15.
Zancanaro PC, McGirt LY, Mamelak AJ, Nguyen RH, Martins CR. Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience. J Am Acad Dermatol. 2006;54(4):581-8.
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4.
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ACCEPTED MANUSCRIPT Quarles FN, Brody H, Johnson BA, Badreshia S, Vause SE, Brauner G, Breadon JY, Swinehart J, Callendar V. Pseudofolliculitis barbae. Dermatol Ther. 2007;20(3):133-6.
18.
Provost TT, Farmer ER. Current Therapy in Dermatology-2. B.C. Decker, Philadelphia, 1988, p. 211.
17.
Kelly AP. Pseudofolliculitis barbae and acne keloidalis nuchae. Dermatol Clin. 2003;21(4):645-53
19.
Maddox JS, Ware JC, Dillon HC. The Natural History of Streptococcal Skin Infection: Prevention with topical antibiotics. J Am Acad Dermatol 1985;13:207-12
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16.
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20. Kligman AM, Mills OH. Pseudofolliculitis of the beard and topically applied tretinoin. Arch Dermatol 1973;107: 551.
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21. Hage JJ, Bouman FG. Surgical depilation for the treatment of pseudofollicuitis or local hirsuitism of the face: experience in the first 40 patients. Plast Reconstr Surg 1991;88: 446-51.
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22. Vasily DB, Breen PC, Miller OF. Acne keloidalis nuchae: Report and treatment of a severe case. J Dermatol Surg Oncol 1979;5: 228-30.
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ACCEPTED MANUSCRIPT FIGURES
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Fig. 1 Impetigo
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Fig. 2
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Fig. 3
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Fig 4
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