Folliculitis

August, 10th, 2023

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Folliculitis is a common skin condition that happens when hair follicles become inflamed. It’s often caused by an infection with bacteria. At first it may look like small pimples around the tiny pockets from where each hair grows (hair follicles).

The condition can be itchy, sore and embarrassing. The infection can spread and turn into crusty sores.

Mild folliculitis will likely heal without scarring in a few days with basic self-care. More-serious or repeat infections may need prescription medicine. Left untreated, severe infections can cause permanent hair loss and scarring.

Certain types of folliculitis are known as hot tub rash and barber’s itch.

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Symptoms

Folliculitis signs and symptoms include:

• 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 bump

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Types of folliculitis

The two main types of folliculitis are superficial and deep. The superficial type involves part of the follicle, and the deep type involves the entire follicle and is usually more severe.

Types of folliculitis, with the most common listed first, include:

• Bacterial folliculitis. This common type is a rash of itchy, pus-filled bumps. It occurs when hair follicles become infected with bacteria, usually Staphylococcus aureus (staph). Staph bacteria live on the skin all the time. And they can cause problems when they enter the body through a cut or other wound.
• Hot tub rash (pseudomonas folliculitis). This type is a rash of round, itchy bumps that can show up 1 to 2 days after exposure to the bacteria that causes it. Hot tub folliculitis is caused by pseudomonas bacteria, which can be found in hot tubs, water slides and heated pools in which the chlorine and pH levels aren’t correct.
• Razor bumps (pseudofolliculitis barbae). This rash can look like folliculitis but it’s caused by ingrown hairs, not infected follicles. It mainly affects people with curly hair who shave too close and is most noticeable on the face and neck. People who get bikini waxes may get razor bumps in the groin area.
• Pityrosporum (pit-ih-ROS-puh-rum) folliculitis. This type is a rash of itchy, pus-filled bumps, most often on the back and chest. It’s caused by a yeast infection.
• Gram-negative folliculitis. This type causes pus-filled bumps around the nose and mouth. It sometimes develops in people who are receiving long-term antibiotic therapy for acne.
• Eosinophilic (e-o-sin-o-FILL-ik) folliculitis. This type causes intense itching and recurring patches of bumps and pimples that form near hair follicles of the face and upper body. It mainly affects people with HIV/AIDS. The cause of this condition isn’t fully understood.
• Boils (furuncles) and carbuncles. These occur when hair follicles become deeply infected with staph bacteria. A boil tends to appear suddenly as a painful inflamed bump. A carbuncle is a cluster of boils.
• Sycosis barbae. This type affects people who shave.

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Make an appointment with your health care provider if your condition is widespread or the symptoms don’t go away after a week or two of self-care measures. You may need a prescription-strength antibiotic or antifungal medication to help control the condition.

Seek immediate medical care if you experience signs of a spreading infection. These include a sudden increase in redness or pain, fever, chills, and a feeling of being unwell (malaise).

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Causes

Folliculitis is often caused when hair follicles are infected with bacteria, commonly Staphylococcus aureus (staph). It may also be caused by viruses, fungi, parasites, medications or physical injury. Sometimes the cause isn’t known.

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Anyone can develop folliculitis. Certain factors increase the risk of getting it, including:

• Regularly wearing clothing that traps heat and sweat, such as rubber gloves or high boots
• Soaking in a hot tub, whirlpool or public pool that’s not maintained well
• Causing damage to hair follicles through shaving, waxing, wearing tight clothes or hair styling practices such as traction, wigs and oils
• Using some medications, such as corticosteroid creams, prednisone, long-term antibiotic therapy for acne and certain chemotherapy drugs
• Having dermatitis or excessive sweating (hyperhidrosis)
• Having diabetes, HIV/AIDS or another condition that lowers your resistance to infections

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Complications

Possible complications of folliculitis include:

• Recurrent or spreading infection
• Permanent scarring
• Patches of skin that are darker (hyperpigmentation) or lighter (hypopigmentation) than before the condition occurred, usually temporary
• Destruction of hair follicles and permanent hair loss

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Prevention

You can try to prevent folliculitis by using these tips:

• Wash your skin regularly. Use a clean washcloth and towel each time and don’t share your towels or washcloths.
• Do laundry regularly. Use hot, soapy water to wash towels, washcloths and any oil-soaked uniforms or other clothing.
• Avoid friction or pressure on your skin. Protect skin that’s prone to folliculitis from the friction caused by backpacks, helmets and tight clothes.
• Dry out your rubber gloves between uses. If you wear rubber gloves regularly, after each use turn them inside out, wash with soap, rinse and dry well.
• Avoid shaving, if possible. For people with facial folliculitis, growing a beard may be a good option if you don’t need a clean-shaven face.
• Shave with care. If you shave, adopt these habits to help control symptoms:
  • Shaving less often
  • Washing your skin with warm water and a mild facial cleanser (Cetaphil, CeraVe, others) before shaving
  • Using a washcloth or cleansing pad in a gentle circular motion to raise embedded hairs before shaving
  • Applying a good amount of shaving lotion before shaving
  • Shaving in the direction of hair growth
  • Avoiding shaving too close by using an electric razor or guarded blade and by not stretching the skin
  • Using a clean, sharp blade and rinsing it with warm water after each stroke
  • Avoiding shaving the same area more than twice
  • Applying moisturizing lotion after you shave
  • Avoiding the sharing of razors, towels and washcloths
• Try hair-removing products (depilatories) or other methods of hair removal. Though they, too, may irritate the skin.
• Treat related conditions. If you know that a condition other than folliculitis is triggering your symptoms, treat that condition. For example, excessive sweating (hyperhidrosis) can cause folliculitis. You can try to prevent this by changing out of sweaty clothing, bathing daily and using antiperspirant.
• Use only clean hot tubs and heated pools. The Centers for Disease Control also suggests that after getting out of the water you remove your swimsuit and shower with soap. Then wash your swimsuit too. If you own a hot tub or a heated pool, clean it regularly and add chlorine as recommended.
• Talk with your health care provider. If your folliculitis often returns, your health care provider may suggest controlling bacterial growth in your nose. You might need a five-day course of a prescription antibacterial ointment. And you may need to use a body wash with chlorhexidine (Hibiclens, Hibistat, others).

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Diagnosis

Your health care provider will likely be able to tell whether you have folliculitis by looking at your skin and asking about your medical history.

If early treatments don’t clear up your infection, your health care provider may run some tests. These tests might include:

• Scraping of the skin to look for yeast under the microscope
• Obtaining a swab for culture to determine the cause of infection
• Rarely, doing a skin biopsy to rule out other conditions

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Treatment

Treatments for folliculitis depend on the type and severity of your condition, what self-care measures you’ve already tried, and how you’d like to proceed.

If you’ve tried nonprescription products for a few weeks and they haven’t helped, ask your health care provider about prescription-strength medications. A dermatologist can help you:

• Control your folliculitis
• Figure out whether a drug you take might be causing your symptoms and whether you can stop taking it
• Avoid scarring or other damage to the skin
• Make scars less noticeable

Even if treatment helps, the infection may come back. Talk with your health care provider about the risks of the treatments you’re considering.

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Medications

• Lotions, gels or pills to control bacterial infection. For mild infection caused by bacteria, your health care provider may prescribe an antibiotic lotion or gel. Infection-fighting pills (oral antibiotics) aren’t routinely used for folliculitis, but you may need them for a severe or repeat infection.
• Creams, shampoos or pills to fight fungal infections. Antifungals are for infections caused by yeast rather than bacteria. Antibiotics aren’t helpful in treating this type of folliculitis.
• Creams or pills to calm inflammation. If you have mild eosinophilic folliculitis, your health care provider may suggest you try a steroid cream to ease the itching. If you have HIV/AIDS, you may see improvement in your eosinophilic folliculitis symptoms after antiretroviral therapy.

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Other interventions

• Minor surgery. If you have a large boil or carbuncle, your health care provider may make a small cut in it to drain the pus. This may relieve pain, speed recovery and lower the risk of scarring. Your health care provider may then cover the area with sterile gauze to absorb any leaking pus.

• Laser hair removal. Your health care provider may suggest laser hair removal as an option for pseudofolliculitis barbae, especially when other treatments haven’t improved your symptoms. This treatment often requires multiple visits to the health care provider’s office.

  Talk with your health care provider about possible side effects of laser treatment. They include scarring and skin that lightens (hypopigmentation) or darkens (hyperpigmentation).

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Self care

Mild cases of bacterial folliculitis often improve with home care. The following self-care tips may help relieve discomfort, speed healing and prevent an infection from spreading:

• Apply a warm, moist washcloth. Do this several times a day to relieve discomfort and help the area drain, if needed. Moisten the washcloth with a vinegar solution made of 1 tablespoon (17 grams) of table white vinegar in 1 pint (473 milliliters) of water.
• Apply a nonprescription antibiotic. Try one of the many infection-fighting lotions, gels and washes that are available in stores without a prescription.
• Apply a soothing lotion or cream. Try relieving itchy skin with a soothing lotion or a nonprescription-strength hydrocortisone cream.
• Clean the affected skin. Gently wash the infected skin at least twice a day with an antibacterial soap or cleanser, such as benzoyl peroxide. Use a clean washcloth and towel each time and don’t share your towels or washcloths. Use hot, soapy water to wash these items.
• Protect the skin. If you shave, stop if you can. Barber’s itch usually clears up a few weeks after you stop shaving.

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Preparing for your appointment

You’re likely to start by seeing your primary care provider. You may then be referred to a doctor who specializes in the diagnosis and treatment of skin conditions (dermatologist).

Here’s some information to help you get ready for your appointment.

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What you can do

• List your key medical information, such as other conditions you’re dealing with and any medications, vitamins and supplements you’re using.
• List key personal information, including any major stresses or recent life changes.
• List questions to ask. Having a list ready can help you make the most of your time with your health care provider.

Below are some basic questions to ask your health care provider about folliculitis. If any other questions occur to you during your visit, don’t hesitate to ask.

• What’s the most likely cause of my symptoms?
• What are other possible causes for my symptoms?
• Do I need any tests?
• What’s the best treatment for my condition?
• I have these other health conditions. How can I best manage them together?
• What are the possible side effects of the treatment you’re recommending?
• Is there a generic alternative to the medicine you’re prescribing me?
• Do you have any relevant brochures or other printed material that I can take home with me? What websites do you recommend?
• What will determine whether I should plan for a follow-up visit?

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What to expect from your health care provider

Your health care provider is likely to ask you a few questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your health care provider may ask:

• How long have you had this skin infection?
• Do you have a history of dermatitis?
• Does your work or a hobby expose your hands to heat and moisture, such as from wearing rubber gloves?
• Were you in a hot tub or a heated swimming pool a day or two before you noticed your skin rash?
• Have your symptoms been continuous or occasional?
• Does your skin itch? Is it painful to the touch?
• Does anything make your symptoms worse?
• What treatments or self-care steps have you tried so far? Have any been effective?

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What you can do in the meantime

Sometimes folliculitis goes away without medical treatment. Self-care measures may help relieve your symptoms. For example, it might help to apply a warm, moist washcloth to the affected skin, followed by an anti-itch cream.