Folliculitis - Causes, Symptoms and Treatment

A Common Skin Infection Can Turn Severe in People with HIV

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Uncomplicated folliculitis on the back of the neck. Photograph © Lforlav

For a teenager, acne and pimples are simply part of growing up. But as adults, irritating skin conditions can sometimes rear their ugly heads, no more so than in people living with HIV. Among the more common conditions is folliculitis, a skin disorder which can manifest, often profoundly, in HIV-infected people with severely compromised immune systems.

What is Folliculitis?

Folliculitis is defined as an inflammation or infection of hair follicles.

Folliculitis can occur anywhere there is body hair, but most often appears in areas that are either irritated from shaving, chafed from rubbing clothes, or blocked by oils and dirt in pores. The most common sites of folliculitis are the face, scalp, leg, under the arms, and on the chest and back.

What Causes Folliculitis?

Typically, folliculitis occurs when hair follicles become damaged or obstructed, providing a perfect breeding ground for bacteria or fungus. Some of the most common infective agents are:

In people with HIV, these infections can be more profound and appear at far greater rates than the general population. This type of folliculitis, called eosinophilic folliculitis, is commonly seen in people whose CD4 count is below 200 cells/mL and can present profusely—most typically on the upper body (although generally not on the abdomen and arms).

What are the Signs and Symptoms of Folliculitis?

The symptoms of folliculitis can vary from person to person, but usually presents with:

  • a reddened rash
  • raised pus-filled lesions (pustules)
  • crusted lesions that have opened and drained pus
  • itching at the site of the lesions

In cases of eosinophilic folliculitis, these manifestations are often profound and extremely itchy with pustules on the face, neck, scalp and trunk.

How is Folliculitis Diagnosed?

The diagnosis of folliculitis is generally made by a physical examination of the skin and the lesions. On occasion, a skin biopsy will be done, although this is primarily done to rule out other possible cause. A culture of the lesion may also help reveal if a particular fungus or bacteria has caused the infection.

What is the Treatment for Folliculitis?

If you are affected with folliculitis, you can help minimize the symptoms by taking a couple of simple precautions:

  • Wear looser clothes that don't rub directly against the skin. This includes hosiery or elastic socks if you are affected on the lower extremities.
     
  • Try shaving with an electric razor as opposed to a blade razor.
     
  • Keep the skin clean using soap, water, and mild skin cleansers. Avoid exfoliators and scrubs, as well as face masks and strong astringents. Keeping yourself well hydrated will also benefit the skin and can potentially reduce symptoms.

Treatment largely depends on what is causing the infection and how severe it is and can include

  • antibiotic ointments for bacterial infections
  • antifungal creams for fungal infection
  • antibiotic or medicated shampoos for folliculitis of the scalp

In persons with HIV, the implementation of antiretroviral therapy (ART) is considered the first-line treatment.  Since this type of folliculitis manifests most often during advanced disease, the use of ART to restore immune function can generally resolve the condition in between 3-6 months.  In some cases, the drugs itraconazole and/or permethrin 5% cream may be prescribed in tandem with ART for those with more severe manifestations.

Edited by James Myhre and Dennis Sifris, M.D.

Source:

Fearfield, L.; Rowe, A.; Francis, N.; et al. "Itchy folliculitis and human immunodeficiency virus infection: clinicopathological and immunological features, pathogenesis and treatment." British Journal of Dermatology. 2009; 141(1):3–11.

U.S. Department of Veteran Affairs. "Dermatologic Conditions: Primary Care of Veterans with HIV - Organ Systems and Metabolic." October 8, 2011; Washington, D.C.

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