Folliculitis is a common skin condition that usually involves infection or inflammation of the hair follicle. While generally benign, prompt recognition and appropriate management can significantly improve a patient's quality of life. Herpetic folliculitis (HF) is a rare manifestation of herpes virus infection of the skin.
Folliculitis is a common, generally benign skin condition characterized by inflammation or infection of hair follicles, leading to the formation of pustules or erythematous papules on hair-covered skin. While typically not life-threatening and often self-limiting, it can pose challenges for immunocompromised patients and, in some instances, progress to more severe conditions.
Folliculitis is most commonly caused by bacterial infection of the superficial or deep hair follicle. However, this condition may also be caused by fungal species, viruses and can even be noninfectious in nature. Several of the causative agents of folliculitis are listed below and include:
Herpetic folliculitis (HF) is a rare disease involving hair follicles and sebaceous epithelium, which is caused by varicella zoster virus (VZV) or herpes simplex virus (HSV). These viruses can cause skin or mucosal infections, and thus produce primary and recurrent infections. However, HF is uncommon in the literature and is present in a variety of forms in the clinic.
While the precise incidence of folliculitis is not currently known, patients with a history of diabetes, obesity, prolonged use of oral antibiotics, immunosuppression, or frequent shaving are at higher risk. Gender does not correlate with an increased incidence of folliculitis, but there may be a correlation between the type of folliculitis and gender. For example, Malassezia folliculitis is commonly seen in men more than women.
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Most commonly, infection of the hair follicle is the mechanism behind most folliculitis cases. Even so, folliculitis may also result from fungal or viral infections, but this does not mean that all folliculitis cases are infectious. Sometimes, folliculitis may be the result of inflammation secondary to ingrown hairs as well as caused by certain drugs such as lithium and cyclosporine.
In the vast majority of cases of folliculitis, histopathology is not needed for diagnosis as this condition is a clinical diagnosis. However, in the case of eosinophilic folliculitis skin biopsy should be done for confirmation of the diagnosis. These biopsies would show perifollicular infiltrates that include lymphocytes and eosinophils predominantly around the area where the sebaceous gland and duct meet follicle. Uncommonly, the clinician may need to perform a skin biopsy to differentiate folliculitis from a condition that may mimic it. In cases of bacterial folliculitis, a biopsy would show a neutrophilic invasion of the hair follicle.
A complete history, as well as a focused physical exam, is usually enough to elucidate the diagnosis. Essential elements of history should include:
Physical exam should include close inspection of hair-bearing areas, including the bilateral upper and lower extremities as well as the chest, back, face, and scalp. On exam, the clinician should look for small pustules in these areas with peri-follicular inflammation.
The diagnosis of folliculitis is clinical. In general, no diagnostic testing or radiographic evaluation is necessary to diagnose this condition in lieu of a thorough history and physical exam. A standard KOH preparation can be used to visualize hyphae and spores associated with folliculitis caused by Malassezia. KOH preparation could also be used to diagnose Demodex folliculitis; however, this is not common in clinical practice. Also, a skin biopsy is usually required to confirm the diagnosis of eosinophilic folliculitis.
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Treatment strategies vary depending on the specific type and severity of folliculitis.
Patients usually suffered pain or pruritus when folliculitis appeared. One patient who had a pregnancy was advised to use Compound Phellodendron Liquid through wet compressing and lesions improved after ten days. The other 19 patients’ lesions improved with antiviral drugs within seven days.
Several conditions can mimic folliculitis, making accurate diagnosis essential. These include:
As this condition is generally benign and often self-limiting, the outlook and prognosis are very good for a full recovery. With proper hygiene and management of any underlying conditions, recurrence rates can remain minimal.
While typically benign, folliculitis can lead to complications such as:
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In the vast majority cases of folliculitis, the only therapy needed is time, as most cases will resolve spontaneously. More severe cases can be managed medically with either antibiotic, antifungal, or anti-parasitic agents. Patients should be counseled on proper hygiene for the affected area as well as the use of warm compresses several times daily for up to 15 minutes on the affected area. Patients should also receive counsel against scratching or shaving the affected areas as this could cause increased irritation and could potentially spread the causative agent.
Folliculitis is a very common condition that can easily be identified by all members of the healthcare team, including primary care physicians, nurse practitioners, physician assistants, and nursing staff. All of these individuals can play essential roles in the diagnosis and patient education of this condition.
Proper hygiene is of paramount importance to prevent recurrence as well as to facilitate the resolution of this condition. In more severe cases, medical therapy may be necessary. In these cases, the local pharmacist can be consulted to help determine correct coverage for the underlying causative agent for these patients. However, most cases of folliculitis are self-limiting and will resolve on their own with proper home care.
Should these cases prove to be too extensive, do not resolve on their own, or don’t resolve after medical management referral to a dermatologist is recommended. A pharmacist can also offer a consult on two fronts; they can verify whether the patient's medication regimen has any drugs that could result in folliculitis, and they can also assist in agent selection, antimicrobial coverage assessment, and perform additional patient counseling. Nursing must also have involvement, including monitoring for treatment effectiveness, counseling on the application of topical agents, and looking for signs of adverse drug reactions. While folliculitis is a generally benign, self-limiting condition, this does not preclude the involvement of an interprofessional team approach to diagnosis and management, resulting in better patient outcomes.
Herpetic folliculitis (HF) is a rare manifestation of herpes virus infection affecting the hair follicles and sebaceous epithelium. It is caused by either varicella-zoster virus (VZV) or herpes simplex virus (HSV). While these viruses are known for causing skin and mucosal infections, leading to primary and recurrent infections, HF is an uncommon presentation that can manifest in various forms.
In a retrospective case series of 20 patients with facial diffused herpetic folliculitis, diagnosed clinically or experimentally, the following observations were made:
Skin biopsies typically reveal viral-induced changes limited to hair follicles or follicular sebaceous glands, without involvement of the interfollicular epidermis. This explains the atypical clinical presentations. Recognition of typical histological features can contribute to an accurate diagnosis. PCR testing can confirm the presence of HSV or VZV.
The major clinical differential diagnosis for HF is bacterial folliculitis, with Staphylococcus aureus as the most common culprit. Eczema herpeticum, also known as Kaposi varicelliform eruption, should also be considered, especially in patients with underlying skin conditions like atopic dermatitis secondary to HSV infection.
HF always develops acutely and diffusely, most often in middle-aged women, with lesions that are easy to rupture and a short-term duration. Treatment typically involves antiviral therapy, such as oral acyclovir, valacyclovir, and famciclovir, similar to the treatment of a normal herpes outbreak. These medications can help to shorten the duration of the outbreak and reduce the severity of symptoms.
To prevent folliculitis, avoid or reduce exposure to the causes of the condition. These include:
A person should also treat underlying medical conditions and speak with a healthcare professional if they are taking medications that increase the risk of folliculitis.
Several home remedies are effective at treating folliculitis and its symptoms. They include:
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