FIGURE 32-32 Infectious folliculitis: Malassezia furfur A 41-year-old Hispanic male with

trunkal rash for 2 months. Multiple, discrete, follicular papulopustules on the chest. Lesional
biopsy showed yeast forms of Malassezia furfur. The lesions resolved after treatment with oral
itraconazole

Infectious Foliculitis

_ Infectious folliculitis begins in the upper portion of
the hair follicle
_ Etiologic agents: Bacteria, fungi, virus, mites
_ Manifestations: Follicular papule, pustule, erosion,
or crust at the follicular infundibulum
_ Infection can extend deeper into the entire length
of the follicle (sycosis).

ETIOLOGY AND EPIDEMIOLOGY
Etiology See Table 32-6.
Predisposing Factors
Shaving hairy regions such as the beard area,
axillae, or legs facilitates follicular infection.
Extraction of hair such as plucking or waxing.
Occlusion of hair-bearing areas facilitates
growth of microbes: clothing, plastic film,
_ Infectious folliculitis begins in the upper portion of
the hair follicle
_ Etiologic agents: Bacteria, fungi, virus, mites
_ Manifestations: Follicular papule, pustule, erosion,
or crust at the follicular infundibulum
_ Infection can extend deeper into the entire length
of the follicle (sycosis).
INFECTIOUS FOLLICULITIS ICD-9 : 704.8 ICD-10 : L73.8 _ _
adhesive plaster, position (sitting occludes
buttocks, lying in bed occludes back), prosthesis,
natural occlusion in intertriginous
sites (axillae, inframammary, anogenital).
Topical climate with high temperature and
relative humidity.
Topical glucocorticoid preparations.
Systemic antibiotic promotes growth of gramnegative
bacteria; diabetes mellitus; immunosuppression.

TABLE 32-6 Classification of Infectious Folliculitis by Etiology
Infectious Agent Organism
Bacterial S. aureus: superficial (Bockhart impetigo); deep (sycosis); may
progress
to furuncle (boil) or carbuncle formation
Pseudomonas aeruginosa (hot-tub) folliculitis; gram-negative folliculitis
Fungal Dermatophytic folliculitis: tinea capitis, tinea barbae, Majocchi
granuloma;
Malassezia folliculitis;
Candida folliculitis
Viral Herpes simplex virus;
Varicella-zoster virus;
Molluscum contagiosum;
Syphilitic Secondary syphilis: alopecia, acneiform
Infestation Demodicidosis
Superficial infection heals without scarring,
but in darkly pigmented individuals, postinflammatory
hypo- and hyperpigmentation.
Extension of infection can progress to abscess
or furuncle formation (Fig. 32-29).

CLINICAL MANIFESTATION
Symptoms S. aureus and dermatophytic folliculitis
can be chronic. Usually nontender or
slightly tender; may be pruritic. Uncommonly,
tender regional lymphadenitis.
Skin Lesions
Papule or pustule confined to
the ostium of the hair follicle,
at times surrounded by an erythematous
halo (Figs. 32-27, 32-
28). Rupture of pustule leads
to superficial erosions or crusts.
Scattered discrete or more frequently
grouped and clustered.
Usually, only a small percentage
of follicles in a region is
infected.
In chronic folliculitis, a full range of lesions is
noted.
Pseudofolliculitis barbae caused by penetration
of the skin by sharp tips of shaved
hairs frequently complicated by S. aureus
secondary infection (see Fig. 32-24).
Distribution Face S. aureus . Gram-negative
folliculitis: resembles or may coexist with acne
vulgaris. Molluscum contagiosum. Demodicidosis
resembles rosacea.
Beard Area S. aureus folliculitis: folliculitis
(sycosis) barbae, most commonly of
shaved beard area Dermatophytic folliculitis:
tinea barbae; papulopustules may coalesce to
deeply infiltrated kerion. Herpes
simplex virus. Molluscum contagiosum.
Demodicidosis resembles
rosacea.
Scalp S. aureus . Dermatophytic.
Neck S. aureus in shaved area and
nape of neck, occipital scalp, especially
in diabetics. Pseudofolliculitis
in shaved area. Keloidal folliculitis
in nape of neck; follicular keloids
to large nodulartumorous keloidal
masses. (see page 986)
Legs Occurs in women who shave
legs. In India, a chronic folliculitis
occurs in young men, lasting for
years. Pustular dermatitis atrophicans
of the legs reported commonly
from West Africa, usually affecting
the shins, sometimes the thighs and
forearms.
Trunk S. aureus in axillae, especially
in those who shave. Pseudomonas
aeruginosa (hot tub) folliculitis
(Fig. 32-30). Malassezia folliculitis.
Candida folliculitis on the back of
hospitalized patients with fever who
lie in supine position.
Buttocks Common site for S. aureus
folliculitis. Dermatophytic.
Variants
S. aureus Folliculitis Can be either
superficial folliculitis (infundibular)
(Fig. 32-27) or deep (sycosis)
(extension beneath infundibulum)
with abscess formation (Figs. 32-28,
32-29). In the shaved beard area,
also known as sycosis vulgaris, or
barbers itch. In severe cases (lupoid
sycosis), the pilosebaceous units may
be destroyed and replaced by fibrous
scar tissue.
Gram-Negative Folliculitis Occurs in individuals
with acne vulgaris treated with oral antibiotics.
Acne typically worsens, having been in
good control. Characterized by small follicular
pustules and/or larger abscesses on the cheeks.
Hot Tub Folliculitis Occurs on the trunk following
immersion in spa water (Fig. 32-30).
Dermatophytic Folliculitis Infection begins
in the perifollicular stratum corneum and
spreads into follicular ostia and hair shafts
(see Section 25). (Fig. 32-31)
Tinea Capitis (see Section 25
In dermatophytic Majocchi granuloma, scattered
papules, pustules and nodules, usually
associated with tinea cruris or tinea corporis.
Malassezia Folliculitis More common in subtropical
and tropical climates. Pruritic, monomorphic
eruption characterized by follicular
papules and pustules on the trunk, most often
on the back (Fig. 32-32), upper arms, and less
often on the neck and face; excoriated papules.
Absence of comedones differentiates it from
acne vulgaris (see Section 25). Synonym : Pityrosporum
folliculitis.
Candida albicans Occurs in sites of occluded
skin such as the back of a hospitalized febrile
patient or under plastic dressing, especially if
topical glucocorticoid preparations are used.
Large follicular pustules (see Section 25).
Herpetic Folliculitis Occurs predominantly in
the beard area (viral sycosis) in men. Characterized
by follicular vesicles and later crusts
(Fig. 32-33).
Molluscum Folliculitis Presents as umbilicated
skin-colored papules in a follicular and perifollicular
distribution over the beard area.
Syphilitic (Luetic) Folliculitis: Secondary
Nonscarring alopecia of the scalp and beard
(alopecia areolaris); moth-eaten appearance.
Synonym : Alopecia syphilitica.
Demodicidosis Clinical presentation: perifollicular
scaling (pityriasis folliculorum or rosacea-
like erythematous follicular papules and
pustules with a background of erythema on the
face. Etiology: Demodex folliculorum .
DIFFERENTIAL DIAGNOSIS
Follicular Inflammatory Disorders Acneiform
disorders (acne vulgaris, rosacea, perioral dermatitis),
HIV-associated eosinophilic folliculitis,
chemical irritants (chloracne), acneiform
adverse cutaneous drug reactions [epidermal
growth factor receptor inhibitors (e.g., erlotinib),
halogens, glucocorticoids, lithium], keloidal folliculitis,
pseudofolliculitis barbae.
Regional Differential Diagnosis Face : acne,
rosacea, perioral dermatitis, keratosis pilaris,
pseudofolliculitis barbae (ingrowing hairs).
Scalp : folliculitis necrotica. Trunk : acne vulgaris,
pustular miliaria, transient acantholytic
disease (Grover disease). Axillae and groins :
hidradenitis suppurativa.

LABORATORY FINDINGS
Direct Microscopy Gram Stain S. aureus:
gram-positive cocci. Also visualizes fungi.
KOH Preparation Dermatophytes: hyphae,
spores. M. furfur : multiple yeast forms; Candida
: mycelial forms.
Culture Bacterial S. aureus, P. aeruginosa ;
gram-negative folliculitis: Proteus, Klebsiella,
Escherichia coli . In cases of chronic relapsing
folliculitis, culture nares and perianal region for
S. aureus carriage.
Fungal Dermatophytes; C. albicans .
Viral Herpes simplex virus (HSV).
Dermatopathology The following features
should be evaluated: Are microorganisms
present? Is the inflammatory infiltrate predominantly
follicular or perifollicular? What region
of the pilosebaceous structure is involved? Is
the inflammatory process acute suppurative
(neutrophilic), chronic lymphocytic, or granulomatous
(foreign-body response to keratin
subsequent to rupture of follicle)? Is any portion
of the pilosebaceous structure destroyed?
DIAGNOSIS
Clinical findings confirmed by laboratory findings.
COURSE AND PROGNOSIS
S. aureus folliculitis can progress to deeper
follicular and perifollicular infection with
abscess (furuncle, carbuncle) or cellulitis.
Infection of multiple contiguous follicles
results in a carbuncle.
Many types of infectious folliculitis tend to
recur or become chronic unless the predisposing
conditions are corrected.
MANAGEMENT
Prophylaxis Correct underlying predisposing
condition . Washing with antibacterial soap or
benzoyl peroxide preparation or isopropyl/ethanol
gel.
Antimicrobial Therapy Bacterial Folliculitis
See Table 24-2.
Gram-negative Folliculitis Associated with
systemic antibiotic therapy of acne vulgaris.
Discontinue current antibiotics. Wash with
benzoyl peroxide. In some cases, ampicillin
(250 mg four times daily) or trimethoprim-sulfamethoxazole
four times daily. Isotretinoin.
Fungal Folliculitis Various topical antifungal
agents. For dermatophytic folliculitis: terbinafine,
250 mg PO for 14 days, or itraconazole,
100 mg twice daily for 14 days. For Candida
folliculitis: fluconazole or itraconazole, 100 mg
twice daily for 14 days.
Herpetic Folliculitis See Herpes Simplex Virus
Infections (Section 27).
Demodicidosis Permethrin cream. Ivermectin,
200 g/kg (usual range, 1218 mg) stat.
Pseudofolliculitis Barbae Rule out secondary
S. aureus infection. Discontinue shaving.
Use beard clipper instead of safety razor.
Destruction of hair follicle: electrolysis; laser
hair removal.