Folliculitis: Types and Treatment for Infected Hair Follicles

Folliculitis is a common, non-life threatening medical condition characterized by inflamed or infected hair follicles. There are several types of folliculitis based on the depth of involvement of the hair follicle and the cause. It can range from a mild condition, which resolves without treatment, to a severe one warranting prescription medications to prevent scarring and permanent hair loss.

What are the different types of folliculitis?

There are primarily two categories of folliculitis based on the depth of involvement of the follicle: superficial and deep.

Different types of superficial folliculitis affects only a portion of the follicle.

Bacterial. This is one of the most common types of folliculitis, usually caused by Staphylococcus aureus. Staphylococcus aureus is a type of bacteria that lives on our skin. It only becomes a problem when it enters the skin through a cut or abrasion. Then it causes an infection.

Hot tub folliculitis. This type is caused by the bacteria, Pseudomonas aeruginosa, which lives in poorly maintained hot tubs and heated pools. If the chlorine and acid levels are not good, this bacteria can thrive.

Razor bumps. This type is also known as pseudofolliculitis barbae. It is caused by irritation from ingrown hairs, not an infection. It commonly affects men with thick curly hair or women who get bikini waxes.

Pityrosporum folliculitis. This type is also known as Malassezia folliculitis because it is caused by the yeast Malassezia furfur. This yeast lives on our skin without causing a problem. It typically affects adolescents with overactive sebaceous glands and excessive sweating. At times, it can be confused with acne.

Viral. Herpes or molluscum viruses, like bacteria, can enter the hair follicles and cause an infection.

Demodex. This type is caused by the mite Demodex folliculorum. It can live on your skin and not cause any issues. Demodex usually only poses a problem if you are immunocompromised.

Going deeper

Here are the different types of deep folliculitis, which affect the entire follicle.

Sycosis barbae. This is a severe scarring type of infectious folliculitis caused by shaving.

Gram-negative folliculitis. This type usually affects acne patients receiving long-term oral antibiotics. Long-term antibiotic usage leads to the growth of more resistant gram-negative bacteria (Enterobacter or Klebsiella).

Furuncles. These are also known as boils. They arise from an infection deep in the hair follicle and result in scarring.

Carbuncles. These arise from a group of several furuncles that occur next to each other. It is caused by an infection of several adjacent follicles and results in scarring.

Eosinophilic folliculitis. This type is not infectious and can arise in babies or immunocompromised adults. The exact cause is unknown, but it results in inflammation of the hair follicles.

What are the signs and symptoms of folliculitis?

The signs and symptoms of folliculitis are based on the type of folliculitis present. The superficial types of folliculitis are characterized by itchy pink-red bumps or pus-filled bumps around the hair follicle. They may also be tender.

Bacteria and viral folliculitis can appear anywhere on the body where there are hair follicles. Hot tub folliculitis affects only the areas of skin immersed in the hot tub or pool. Razor bumps appear in shaven or waxed areas. Pityrosporum and Malassezia occur on the trunk, and Demodex can appear anywhere there are sebaceous glands on the body.

Deep folliculitis presents as painful large red-purple bumps that may not come to a head.

Carbuncles and furuncles can appear anywhere on the body where there are hair follicles. Sycosis barbae appears in shaved areas. The exception is eosinophilic folliculitis, which appears as small, itchy pink-red bumps on the face and upper body.

What are the risk factors for folliculitis?

Anyone can develop certain types of folliculitis. There are several risk factors for the development of folliculitis:

• Immunosuppression, such as HIV or diabetes mellitus.
• Acne.
• Dermatitis or skin disorders.
• Medications, such as steroids or long-term antibiotics.
• Men with thick curly hair.
• Shaving often or waxing.
• Wearing tight-fitting, non-breathable clothing.
• Soaking in a poorly-maintained hot tub or pool.
• Excessive sweating.
• Obesity or being overweight.
• Using non-comedogenic products.

How is folliculitis diagnosed?

Most of the time, dermatologists can diagnose folliculitis based on your clinical presentation and medical history. A swab culture or skin biopsy may be performed in challenging cases.

It is always best and easiest to prevent folliculitis rather than treat it. Here are some ways to prevent it:

• Avoid tight clothing.
• Avoid shaving frequently.
• Shave carefully, slowly, and correctly. Soak the area in warm water for several minutes to soften the hair before shaving. Cleanse the area with antibacterial soap and a clean washcloth. Use shaving cream or gel when shaving. Shave in the direction of the hair growth. Always use a sharp, clean blade each time you shave. Apply a soothing moisturizing lotion after shaving.
• Electric razors are better.
• Never share razors.
• Use depilatory creams or laser hair removal instead of waxing or shaving.
• Make sure hot tubs and heated pools are clean and chemically treated correctly.
• Dry off with clean towels.
• Get out of sweaty clothes immediately.

There are several prescription topical and oral treatment options for cases of folliculitis:

• Antibiotics to treat bacterial infections, such as Staphylococcus or Pseudomonas.
• Antifungals to treat fungal and yeast infections, such as Malassezia.
• Anti-inflammatory agents, such as steroids, to calm inflammation.
• Antivirals to treat viral infections, such as Herpes.
• Anti-parasitics to treat parasite infections, such as Demodex.
• Antihistamines for itchiness.
• Non-steroidal anti-inflammatories (NSAIDs) for pain.

Larger lesions respond well to lancing to drain the pus for a faster recovery.

Hair removal with laser or light treatments can help patients prone to folliculitis by permanently reducing the number of hairs.