for Health Care Providers

Folliculitis

Etiology	Findings/ Distribution	Diagnostic Clues	Management
See Potential ARV Interactions*, below.
Eosinophilic folliculitis (see photo in DermAtlas)	Numerous, extremely itchy pustules on the face, neck, scalp, and trunk	Mainly seen in patients with CD4 counts of <200 cells/µL Can be seen during immune reconstitution in the first 3-6 months on ART Very pruritic, especially on face	Itraconazole* 200-400 mg daily (for anti-eosinophilic effect) Permethrin 5% can be used every other day from the waist up (for drying effect) Should resolve after 6 months on ART
Pityrosporum folliculitis (see photo in DermAtlas)	Erythematous papules and tiny pustules along hair follicles	Looks like a milder version of bacterial folliculitis with much smaller lesions Lesions are smaller and less pruritic than eosinophilic folliculitis Commonly excoriated Less likely to form large pustules Overgrowth of tinea	Ketoconazole* 200 mg PO QD for 3 weeks Follow with maintenance therapy using ketoconazole 2% shampoo twice weekly
Staphylococcus folliculitis	Erythematous papules and pustules along hair follicles	Often excoriated Often draining pus Presents as an erythematous flare MRSA common; consider culture to guide treatment	Presumptive treatment for MRSA: TMP-SMX DS BID, or doxycycline 100 mg BID, treat for 10-14 days If severe, IV antibiotics. Consider vancomycin or clindamycin Nares should be treated with intranasal mupirocin QHS for 5 days If confirmed MSSA: dicloxacillin or cephalexin
Pseudomonal folliculitis	Papular lesions appear within 8-48 hours after exposure	Associated with use of hot tub and wet suit/swimwear (lesions may be concentrated in areas covered by swimwear) In immunocompetent persons, self-limited to 7-14 days	For immunosuppressed persons or those with prolonged or severe cases, consider treating with ciprofloxation for 10 days

From Dermatologic Conditions
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009