Introduction

Definition^1,2

A boil is a type of infected sore of the skin. The sore is shown as red, raised, painful and filled with pus. This infection goes into the deeper layer of the skin and can occur in any area on the skin where there is hair. This includes the back of the neck, face, armpit, groin, scalp, waist, buttocks, etc

Overview^3,4

Boils on the scalp is also known as scalp folliculitis. This condition is a common scalp issue that can happen to anyone regardless of their age or gender. This condition is characterised by small, very itchy bumps on the scalp, most troublesome are often on the frontal hairline. There may be a few or many. The bumps are often hard to leave alone as they itch and often become sore and crusted. This condition is often seen in some patients with acne or male pattern alopecia  (hair thinning). Understanding the symptoms, treatment, and prevention of boils on the scalp is crucial for early detection and timely intervention, which, therefore, prevents complications such as the spread of infection. Educating oneself about these aspects will make individuals able to make informed decisions, seek medical help promptly, and adopt healthy practices. These will ultimately reduce the incidence and recurrence of the scalp boils.

Symptoms of boils on the scalp^5,6

1. A cluster of small pimple-like pustules which form at the base of your hair strands
2. Whiteheads on some of the bumps
3. Pus-filled blisters that break open and crust over
4. Redness and inflammation around the pustules
5. Itchiness and sores
6. Pain and your scalp may hurt when you move your hair
7. Burning sensation on the scalp
8. A fever may develop along with boils. Sometimes, although it is rare, the infection gets worse and penetrates into deep layers of tissue, causing boils.

Types of scalp folliculitis⁷

Folliculitis is broadly classified as superficial and deep. Superficial folliculitis is usually mild and easily treatable. However, deep folliculitis penetrates deeper into the hair follicle making it difficult to treat and remove.

1. Superficial folliculitis
   • Bacterial folliculitis
     • This is an infection of follicles that is caused by bacteria. The bacteria that live on the skin enter the follicles through a cut or wound and are characterised by an itchy or pus-filled bump. The cause is usually a bacteria called Staphylococcus aureus.
   • Pseudofolliculitis barbae
     • This condition is also known as razor bump or barber’s itch. It mainly affects men with curly hair who save too close, and caused by ingrown hair. 
   • Pseudomonas folliculitis
     • One or two days after exposure to the bacteria then you will develop a rash, round, itchy bump. Also known as hot tub folliculitis.
   • Pityrosporum Folliculitis
     • This type is caused by a yeast infection and produces itchy and red bumps.
2. Deep Folliculitis
   • Boils and Carbuncles: Boils happen when the hair follicles are deeply infected with bacteria. It usually appears as a painful pink purple or red bump, whereas carbuncles are several boils that merge into bigger bumps that are also painful.
   • Sycosis Barbae: A deeper bump that is similar to a razor bump, and may cause scarring in your scalp in some cases.
   • Gram-negative Folliculitis: This type is sometimes developed when someone is receiving long-term antibiotics therapy which can disrupt the normal bacterial balance of the skin. 
   • Eosinophilic Folliculitis: Those who have a weakened immune system are more likely to develop this. The symptoms include intense itching and recurring patches of bumps and pimples that form near the hair follicles of the face and upper body.

What causes scalp folliculitis^7,8

1. Bacterial infection
2. Fungi/yeast infection
3. Viruses
4. Parasites
5. A weakened immune system (Diabetes, malnutrition, HIV, autoimmune disease, receiving chemotherapy or immunosuppressive treatment)
6. Wearing a helmet for a long time
7. Have scalp conditions such as seborrheic dermatitis
8. Irritants: this includes hair products, which can clog your follicles over time, and chemicals that are found in some swimming pools or a shared hot tub or warm pool that is unclean or using unchlorinated water
9. Have been shaving your head frequently
10. Long-term use of topical antibiotics
11. Tie your hair too tight

Treatment

It is common for mild forms of scalp folliculitis to resolve themselves in about 7-10 days or just need home treatment, without medical intervention. Doctors are usually able to diagnose the bumps by inspecting them. They may also take a sample of the pus from the bumps to test what is the underlying cause -either bacteria, fungus, or parasites. If it is confirmed as folliculitis, then the doctor may also take hair follicles to be tested for bacteria or fungus. If the symptoms persist or worsen in time, treatment will likely be needed to prevent the infection from spreading or causing damage to your hair follicles, scarring, or hair loss.^7,9

1. Home treatment.¹⁰
   • Wash your scalp gently with an antibacterial soap to remove bacteria which may be causing your infection.
   • Don’t shave, wax or pluck your hair until the area heals.
   • If you have dandruff or seborrheic dermatitis, you can wash your scalp with an anti-dandruff shampoo, as the same fungus which is causing these conditions may also be causing scalp folliculitis.
   • Apply a warm compress to the affected area for at least 10-15 for several times a day. This will help to soothe the area and reduce itching.
   • Some essential oils such as tea tree oil, cinnamon oil, and chamomile oil are known to have antibacterial and antifungal effects that can be useful in controlling scalp folliculitis.
   • Scalp hygiene: it is essential to maintain good scalp hygiene to prevent it spreading and recurring flare-ups. Wash your hats, headscarves (hijab) or any other garments that are in regular contact with your scalp. When the condition has subsided it is also important to wash your scalp regularly to prevent build-up products or oil that will cause another irritation.
2. The medication or intervention for scalp folliculitis varies in accordance with the microorganisms which caused it:^1,7,12
   • Bacterial: topical/oral antibiotic (fusidic acid gel, clindamycin, and erythromycin)
   • Viral: If needed, antivirals such as aciclovir or valaciclovir, antihistamines
   • Fungal: Topical antifungal creams lotions, or shampoos. It is advisable to pick an anti-dandruff formula that contains ingredients such as tea tree oil, ketoconazole, or selenium sulphide
   • Eosinophilic Folliculitis: Although prompt resolution might occur, medication such as topical or oral corticosteroid might be needed in this condition
   • In surgery, for example, doctors may make a small cut (incision) in the skin to allow pus to drain out. When the pus is completely drained, antibiotics are usually not needed. However, antibiotics that are taken by mouth might be given for some conditions, such as for someone who has underlying conditions such as a weakened immune system, the person has fever or many abscesses

Prevention^1,12

1. Personal hygiene
   • Keep your scalp clean, especially in hot and humid weather
   • Avoid wearing hats for a long period of time in a hot environment
   • Wash your hands thoroughly before touching your scalp
   • Make sure to use cleaned instruments before shaving/cutting your hair.
   • Avoid tying your hair too tight
   • Avoid sharing personal items such as a comb, towel, or any head accessories. 
   • Do not scratch the bump to avoid it getting worse
   • Avoid frequent use of warmed public pools or hot tubs, and make sure to wash your hands after using
2. Monitoring and early intervention if needed
   • Prompt treatment for minor skin issues
   • Regular medical check-ups for those with chronic conditions
   • Healthy diet and lifestyle
   • Managing stress
   • Avoiding triggers

Summary: Boils on the scalp

Boils, or scalp folliculitis, are painful, pus-filled infections of hair follicles that can occur on the scalp. Symptoms include itchy, red bumps, sometimes accompanied by fever. This condition can arise from bacterial infections, fungal infections, and various irritants, especially in individuals with weakened immune systems.

Treatment varies depending on the cause, ranging from home remedies like warm compresses and antibacterial soap to medications such as antibiotics or antifungals. In severe cases, surgical drainage may be necessary.

Prevention focuses on maintaining good personal hygiene, avoiding prolonged use of hats, and steering clear of shared personal items. Regular scalp care and monitoring for early intervention are crucial for managing this condition effectively.