Folliculitis is a common skin condition, and it would not be surprising to have come across it at least once. Despite being mostly benign and self-limiting, folliculitis can be incredibly uncomfortable for the person, especially if it keeps reappearing. If that sounds familiar, check out the article below, which covers ways to prevent folliculitis.
Preventative strategies include avoiding baths and swims in poorly sanitised places, careful shaving, moderate use of steroids, antibiotics and cosmetic products, and maintaining good hygiene.
If you have ever had folliculitis or want to reduce your risk of developing it, keep reading as we break down what it is, its causes, risk factors, treatments and prevention strategies.
Folliculitis is an inflammation of the hair follicles. There are many causes of folliculitis, but it generally presents as inflamed hair follicle causing bumps on the skin in the form of papules or pustules that resemble rash or acne. Folliculitis can affect any body area that has hair, including the back, arms, legs and buttocks. Folliculitis is a common and typically benign skin condition that usually resolves without treatment. However, sometimes it can present challenges for people with the weak immune system, and also can progress into more severe skin conditions if poorly or insufficiently treated.5,9
Types of folliculitis
There are two general types of folliculitis, depending on how much of the hair follicle is inflamed. It can be superficial, affecting the upper portion of the hair follicle called the infundibulum. It can also be classified as deep folliculitis, where the inflammation spreads deeper into the follicle and the surrounding dermis. Deep folliculitis is more severe and painful. Lesions from superficial folliculitis can give rise to deep folliculitis and cause permanent scarring.9
Less often, folliculitis can also be classified based on a) how chronic the condition is, b) whether it is acute or recurring and c) based on the underlying cause of folliculitis – infectious (bacterial, fungal, viral) or non-infectious (e.g., contact reaction, drug-induced).9 In the next section of the article, we will cover infectious and non-infectious causes of folliculitis.
Causes and symptoms
What causes Folliculitis
As mentioned before, folliculitis can have infectious and non-infectious causes. So let’s look at infectious causes first:
- Bacterial folliculitis is most commonly caused by bacteria infecting a hair follicle. Staphylococcus aureus folliculitis is the most common type of bacterial folliculitis. Other types of bacterial folliculitis include: ‘spa pool’ or ‘hot tub’ folliculitis (caused by Pseudomonas aeruginosa) and gram-negative folliculitis (caused by such bacteria as Klebsiella, Proteus mirabilis or Serratia marescens)8,9
- Fungal folliculitis is caused by fungal organisms infecting hair follicles. One of the most common types of fungal folliculitis is Malassezia (pityrosporum) folliculitis. This condition is common, has a similar clinical presentation to acne vulgaris, and is sometimes misdiagnosed. Other fungal organisms that may cause folliculitis include Dermatophytes and Candida albicans (very rare)4,6,11,12
- Viral folliculitis is caused by viruses such as Herpes simplex, Varicella zoster and Molluscum. The most common viral cause is the herpes virus which presents very similar to bacterial folliculitis. Viral folliculitis is more common in people with a weakened immune system3,7
Non-infectious causes include:
- Contact reaction: folliculitis may be caused by external products, such as topical steroids, moisturisers and irritant chemicals. Perioral dermatitis is a type of facial folliculitis most commonly due to steroid overuse. However, research suggests that perioral dermatitis has been linked to the use of nasal and inhaled corticosteroids and some cosmetic products (moisturisers, sunscreen, foundation). The treatment usually involves discontinuation of using the products. However, a person may require further treatment in severe and chronic cases9
- Irritation from hair removal: folliculitis can result from skin irritation due to hair removal methods, including shaving, laser treatment, waxing and plucking. It commonly presents as a rash in the lower legs of women and the beard area of men. It is usually very itchy and uncomfortable. No treatment is necessary, but it is highly recommended to wait until folliculitis has resolved and adopt more gentle hair removal methods that do not cause skin irritation13
- Weakened immune system: immunosuppression-associated eosinophilic folliculitis occurs in immunocompromised patients. It has been reported in individuals with HIV infection, leukaemia, and lymphoma, among other diseases2
- Drug-induced: folliculitis may be a side-effect of such drugs as antibiotics, hormones, steroids, immunosuppressants, lithium and vitamin B complexes. These drugs have been linked to follicular eruptions that appear soon after starting the drugs
What are its symptoms
The general symptoms of folliculitis include:
- Bumps in your skin that might be filled with liquid or pus. Sometimes these bumps resemble a rash or acne. The colour tends to vary depending on the type of folliculitis but can be yellow, red or white. Bumps can present as papules, pustules or plaques
- Itchiness in the affected area
- Soreness and pain in the affected and nearby areas
However, the clinical presentation of folliculitis may change depending on the underlying cause:
- Bacterial folliculitis: usually presents in the form of erythematous pustules, small bumps on the skin membrane that are filled with either liquid or pus, and look a little reddish due to accumulation of blood in this small region. Overall, pustules look like pimples that can be itchy, uncomfortable and sometimes painful. Different body areas might be affected depending on the type of bacterial infection. If one has Staphylococcus aureus folliculitis, the areas most likely to be affected are the scalp and face. People with Pseudomonas aeruginosa infection usually experience the symptoms all over their bodies within 24 hours of bathing or swimming in the pool8
- Fungal folliculitis: clinically characterised by small skin lesions that look similar. The lesions can be papules or pustules and, therefore, can present with and without liquid and/or pus. Commonly affected areas include the neck, shoulders and back4,6,11,12
- Viral folliculitis: clinical presentation varies, is complex, and can include plaques (raised skin lesions), papules, pustules and vesicles (fluid-filled raised lesions). Herpes virus infection usually presents in clusters in different areas of the body. Molluscum infection presents in a very distinctive way in the form of umbilicated cutaneous lesions3,7
- Perioral dermatitis: presents as scaly patches around the mouth, accompanied by small pink bumps in the form of papules or pustules. It is more common in females
- Immunosuppression-associated eosinophilic folliculitis: usually appears in the form of papules and pustules in the areas usually affected by acne. This type of folliculitis is resistant to treatment but usually improves as the immune system becomes stronger2
Diagnosis and treatment
How is folliculitis diagnosed
Most of the time, your healthcare provider will be able to make a folliculitis diagnosis by taking your medical history, asking about the duration and characteristics of your symptoms and inspecting your skin. If the cause of folliculitis is challenging to identify during a clinical examination, the doctor might refer you to a dermatologist and order further tests to confirm the diagnosis and determine the cause of your symptoms. The diagnostic tests mainly utilised depend on the infectious cause. For instance, a bacterial infection could be diagnosed during a clinical examination. However, fungal and viral folliculitis may require additional work by your dermatologist and can include cell histology and biopsy.5,9
Treatment depends on the underlying cause of folliculitis and its severity. While usually, folliculitis is mild, self-limiting and either does not require any treatment or minimal over-the-counter medication (e.g., non-steroidal anti-inflammatory drugs, antihistamines), there are cases of more severe folliculitis that require medical attention.5,9 Here is the breakdown of treatment options based on the cause of folliculitis:
- Bacterial: treatment for bacterial folliculitis can include improved and careful hygiene, frequent use of antiseptic cleanser and prescription of topical or oral antibiotics
- Fungal: fungal folliculitis is treated with antifungal medication. The most common treatment option is the application of topical antifungal creams to reduce yeast infection. However, if the fungal folliculitis is severe and can’t be treated with topical medication, your healthcare provider might prescribe oral antifungal drugs (e.g., fluconazole)
- Viral: if the identified cause of folliculitis is viral, a person can be treated with several antiviral agents, such as aciclovir. Once you have started the prescribed medication, the symptoms tend to resolve within ten days. Your healthcare provider adjusts the dose of the drug according to the clinical presentation of folliculitis and your medical history
Several potential factors might increase your chance of developing folliculitis in its different forms:
- Hot tub and swimming pool use: pseudomonas folliculitis can occur from bathing or swimming in a pool with contaminated warm water. Therefore, frequently using hot tubs and swimming pools can increase your risk of developing pseudomonas folliculitis, especially if you are uncertain about the cleanliness and disinfection measures of those facilities
- Excessive sweating
- Blocked hair follicle
- Chronic use of oral or topical steroids
- Chronic use of oral or topical antibiotics
- Shaving against the hair follicle: irritates and increases the risk of folliculitis or ‘shaving rash’
- Scratching in the area
- Being assigned male at birth (AMAB): AMAB individuals have an increased risk of developing specific types of folliculitis, such as Malassezia
- Weak immune system
Prevention strategies largely depend on whether you have had any form of folliculitis before and, if so, what was the underlying cause. If you have never had folliculitis and want to minimise your chances, feel free to skim through the list below and adapt strategies that appeal to you. However, if you have previously had folliculitis, it is advisable to focus on the preventative strategies that correspond to the type and cause of folliculitis you had before.
Ways to prevent folliculitis
So what are the ways to prevent folliculitis?
- Shave with care and in the direction of the hair follicle
- Avoid baths and swims in places you believe may not be properly sanitised
- Avoid sharing personal hygiene products and towels
- Take showers after you have sweated
- Restrain from wearing tight clothes
- Do not overuse steroids/antibiotics
- Use cosmetic products with caution and moderation
When to see a doctor
Make sure to book an appointment with your healthcare provider if you experience severe discomfort due to the symptoms of folliculitis (e.g., increased itchiness, redness, pain) and/or your symptoms have not resolved over 1-2 weeks. In severe cases of folliculitis, you will require prescription medication to treat the infection. Furthermore, it is highly recommended to seek immediate medical attention if you have noticed the infection spreading over to other areas of the body.
Folliculitis is a common and usually benign condition. However, it can still be incredibly uncomfortable, itchy and even painful. Therefore, it is essential to understand when to seek medical help if you have symptoms of folliculitis and how to prevent it from happening. In this article, we covered folliculitis in-depth, explained its causes, and how to decrease your chance of developing it.
- Aram G, Rohwedder A, Nazeer T, Shoss R, Fisher A, Carlson JA. Varicella-Zoster-Virus Folliculitis Promoted Clonal Cutaneous Lymphoid Hyperplasia. The American Journal of Dermatopathology. 2005 Oct;27(5):411–7.
- Basarab T, Russell Jones R. HIV-associated eosinophilic folliculitis: case report and review of the literature. Br J Dermatol. 1996 Mar;134(3):499–503.
- Böer A, Herder N, Winter K, Falk T. Herpes folliculitis: clinical, histopathological, and molecular pathologic observations: Herpes folliculitis: diagnostic criteria. British Journal of Dermatology. 2006 Apr;154(4):743–6.
- Boni R, Nehrhoff B. Treatment of Gram-Negative Folliculitis in Patients with Acne: American Journal of Clinical Dermatology. 2003;4(4):273–6.
- Durdu M, Ilkit M. First step in the differential diagnosis of folliculitis: cytology. Critical Reviews in Microbiology. 2013 Feb;39(1):9–25.
- Jalalat S, Hunter L, Yamazaki M, Head E, Kelly B. An Outbreak of Candida albicans Folliculitis Masquerading as Malassezia Folliculitis in a Prison Population. Journal of Correctional Health Care. 2014 Apr 1;20(2):154–62.
- Jang KA, Kim SH, Choi JH, Sung KJ, Moon KC, Koh JK. Viral folliculitis on the face. British Journal of Dermatology. 2000 Mar;142(3):555–9.
- Laureano AC, Schwartz RA, Cohen PJ. Facial bacterial infections: Folliculitis. Clinics in Dermatology. 2014 Nov;32(6):711–4.
- Luelmo-Aguilar J, S??bat Santandreu M. Folliculitis: Recognition and Management. American Journal of Clinical Dermatology. 2004;5(5):301–10.
- Nomura T, Katoh M, Yamamoto Y, Miyachi Y, Kabashima K. Eosinophilic pustular folliculitis: A published work-based comprehensive analysis of therapeutic responsiveness. J Dermatol. 2016 Aug;43(8):919–27.
- Rubenstein RM, Malerich SA. Malassezia (pityrosporum) folliculitis. J Clin Aesthet Dermatol. 2014 Mar;7(3):37–41.
- Vlachos C, Henning MAS, Gaitanis G, Faergemann J, Saunte DM. Critical synthesis of available data in Malasseziafolliculitis and a systematic review of treatments. J Eur Acad Dermatol Venereol. 2020 Aug;34(8):1672–83.
- Schuler A, Veenstra J, Tisack A. Folliculitis Induced by Laser Hair Removal: Proposed Mechanism and Treatment. J Clin Aesthet Dermatol. 2020 May;13(5):34–6.