Folliculitis means inflammation of the hair follicles of the skin. There are a number of reasons why this happens. Most of the skin is covered with tiny hairs which grow out of hair follicles. In folliculitis, many hair follicles in one area of the skin are affected.
What is folliculitis?
Folliculitis means inflammation of the hair follicles. Folliculitis can be a mild, short-lived condition or a severe long-term problem. Folliculitis can occur anywhere on hair-bearing skin (it could not, for example, occur on the palms of the hands where there is no hair). There are a number of causes of inflammation which can result in folliculitis.
James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons
When hair follicles become infected or inflamed they swell causing a red bump on the skin. You may be able to see a hair coming out of these bumps. Sometimes the affected follicles fill with pus, covering the affected skin with small, rounded, yellow-red spots (pustules). Affected skin may develop a crust, which can be yellow or golden coloured due to infection.
The affected skin can feel painful, hot and may be itchy.
Types of folliculitis
There are a few specific types of folliculitis:
- Sycosis barbae - this is the medical name for a long-term (chronic) folliculitis in the beard area of the face in men (and some women).. The skin is painful and crusted, with burning and itching on shaving. Numerous pustules develop in the hair follicles. It can be difficult to treat and some men grow a beard to solve the problem.
- Hot tub folliculitis - as the name suggests, this tends to affect people after using a hot tub. The hot water encourages a germ (bacteria) called Pseudomonas aeruginosa to grow (particularly if there is not enough chlorine in the water to keep it clean). This type of folliculitis is generally harmless and is prevented by proper maintenance of hot tubs. Showering after using the hot tub does not seem to reduce the chance of folliculitis.
- Gram-negative folliculitis - this is a type of folliculitis that may occur after acne has been treated with long-term antibiotics. Gram-negative refers to a type of stain that is used in a laboratory to identify different types of bacteria.
- Pseudo-folliculitis - also known as "razor bumps". It is caused by inflammation from shaving and ingrowing hairs. Pseudo-folliculitis is more common in people with curly or Afro-Caribbean hair, as these hairs are more likely to curl back and grow into the skin. Ingrowing hairs can also be caused by dead skin cells blocking the hair follicle so the hair cannot exit the follicle.
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Causes of folliculitis
Folliculitis occurs at sites where hair follicles are inflamed. There are a number of causes:
- Infection. Most folliculitis infections are caused by a germ (bacteria) called Staphylococcus aureus (S. aureus). Occasionally other bacteria, fungi (Pityrosporum or Candida albicans) or parasites are the cause.
- Physical irritation caused by shaving or friction by friction or shaving.
- Chemical irritation caused by chemicals applied to the skin.
- Blockage of the hair follicle eg, by dead skin cells or thick creams.
- Excessive sweating (hyperhidrosis) due to overactivity of the sweat glands.
- Steroid creams.
- Inflammatory skin conditions are an uncommon cause.
Complications of folliculitis
Most cases of folliculitis get better without any complications. Occasionally the following can occur:
- Scarring of the skin.
- Darkening of the affected skin (hyperpigmentation).
- Hair loss at the affected site due to scarring of the skin.
- Deep folliculitis. This occurs if the infection spreads deeper into the follicles causing a boil.
- Cellulitis. This is when infection spreads into the surrounding skin, making it hot and red.
If there is an infection which is spreading deeper or onto surrounding skin you should see your GP.
There are no specific tests for folliculitis. If you see a healthcare professional they will ask questions (a medical history) and examine the rash to try and decide whether you have folliculitis and why it has happened. In some cases, for example if you have had treatment and it has not helped, they may take a sample of any pus or crusting (a swab) and send it to the laboratory. This tries to help identify the cause of the rash and what treatment you may need.
Identifying the cause of the folliculitis will help decide what will help. General measures include:
- Avoiding things that aggravate the condition.
- Taking a break from hair removal until the folliculitis has settled down.
- Avoiding wearing tight clothing over the affected area, particularly if it makes you sweat.
- Keeping cool and keeping folliculitis exposed to the fresh air.
- Not sharing towels, flannels or razors.
- Applying an antibacterial moisturiser (emollient) and soap substitute. See below for more information.
Most cases or folliculitis are mild and do not need any treatment. It often clears without any treatment within 7-10 days. It may be helpful to use a moisturiser (emollient) which contains an antibacterial agent - for example, Dermol® cream or lotion or Emulsiderm®. It may help the folliculitis to clear more quickly and reduce the risk of it becoming worse.
You can use one of these emollients as a soap substitute until the folliculitis has cleared. Specific preparations for the bath or shower are available - for example, Dermol® 200 Shower Emollient, Dermol 600® Bath Emollient and Oilatum® Plus bath additive.
If simple measures over a few days do not allow the folliculitis to improve, you should probably see your GP for further advice and treatment.
For localised areas of folliculitis, an antibiotic cream may be useful. Fusidic acid is a suitable antibiotic cream that can be applied 3-4 times per day to affected areas. If you are thought to have a fungal infection, you may be given a different type of medication.
More severe cases
If the folliculitis is more severe or widespread then a course of oral antibiotic tablets may be needed.
Recurrent or long-term (chronic) folliculitis
Recurrent folliculitis occurs when the infection keeps coming back, although it disappears with treatment. The gaps between episodes may get shorter and, eventually, chronic folliculitis is the result.
In these cases, your GP may take a sample (swab) from the skin where the folliculitis is. This swab can show if an infection is responsible and identify which type of infection it is. If the swab confirms S. aureus, it is a good idea to take some more swabs, usually from the nose, to see if you are a carrier of this germ (bacterium). If so, the right medication can then be used to try and eradicate the germ (bacterium) from your skin.
To try and prevent folliculitis you can:
- Keep skin clean, dry and free from abrasions or irritations.
- Keep skin moisturised.
- Use clean, sharp razors and shave in the direction of hair growth or use an electric razor.
- Use a shaving soap, gel or foam to lubricate the blades across the skin to help prevent nicks and cuts.
- Use hair removal methods other than shaving.
- Avoid chemicals or items which irritate your skin.
- Exfoliate regularly to remove dead skin cells.
Is folliculitis contagious?
Most cases of folliculitis are not contagious but if you have recurrent or chronic folliculitis and have been identified as carrying the S. aureus germ (bacterium), this infection can occasionally be transferred to other people. Your doctor will usually treat you to try and eradicate this germ (bacterium) from your skin. Until this is achieved the risk can be minimised by normal hygiene measures, and laundering clothing, bed linens and towels on a hot wash. Do not share razors, towels or flannels. You should also avoid sharing bathing water, hot tubs or using a swimming pool until the infection has been treated.
Further reading and references
Folliculitis; DermNet NZ
Winters RD, Mitchell M; Folliculitis. StatPearls, September 2019.