Folliculitis is a common skin problem that occurs when a hair follicle, a sac under the skin where hair growth starts from, gets infected by bacteria or fungi, or rarely by a virus. It presents as groups of small, raised red bumps or white pus-heads on your skin. Inciting factor is damage to hair follicles that can happen from shaving, adhesive bandages and tight clothing, especially tight-fitting synthetic fabrics that cause heat and sweat trapping. 

The many flavors of folliculitis

  • Hot tub folliculitis is caused by Pseudomonas, same bacterium that causes otitis externa, or swimmer's itch. It is usually found in hot tubs, water slides and heated pools, even if the water is sufficiently chlorinated. It appears on skin as a rash that is extremely itchy or painful. It can resolve on its own in 7-10 days but can also spread and worsen, lasting months.

  • Barber’s itch also known as "pseudo-folliculitis barbae" is caused by ingrown hairs after close shaving on the face and neck in males, and facial and bikini waxing in females. It can cause pus-filled bumps, that can cause scarring and permanent hair loss. It is important to avoid close shaving or traumatic hair removal methods and to treat underlying inflammation to prevent scarring.

  • Pityrosporum folliculitis, also known as "malassezia folliculitis", is caused by infection by malassezia yeast that presents in young adults and men on their chest, back, neck and shoulders, as acne-like bumps and pimples.  It is often misdiagnosed as acne.

  • Sycosis barbae is a chronic infection and deeper inflammation of bearded areas of young men caused by shaving. It is often caused by species of Staphylococcus or Propionibacterium bacteria, and increases in severity of inflammation as trauma of shaving continues. The most common symptoms are intense burning, itching and pain, especially on the upper lip if patients suffer from seasonal allergies and/or nasal discharge. 

  • Gram-negative folliculitis is an acne-like pustular rash caused by a bacterial infection by gram-negative bacteria like Escherichia coli, Pseudomonas aeruginosa, Serratia marcescens, Klebsiella and Proteus species.  It is often mistaken as a worsening of acne as it usually occurs in acne and rosacea patients as a complication of using antibiotic. 

  • A boil is a skin infection caused by staphylococcal bacteria, that enters the body through tiny nicks or cuts in the skin and travels down the hair follicles. At first the skin turns red, and then a boil develops, which is a hard, red, tender dime-sized lump. Then it becomes softer, larger and more tender, turning white as a pocket of pus collects underneath the skin. They usually occur on the face, neck, armpits, shoulders, and buttocks, and can also occur on eyelids as a sty. Patients with history of diabetes, weakened immune system, poor hygiene, and habits of using harsh abrasive and mechanical cleansers are at increased risk for developing boils. 

  • A carbuncle is a more serious infection when several boils occur in a group or cluster.

  • Eosinophilic folliculitis is a noninfectious recurrent skin disorder that presents with acne-like pimples and pus-heads containing white cells called eosinophils, in HIV/AIDS or transplant patients. Itch is a symptom in half the patients. 

What is the treatment for folliculitis?

Application of warm compresses on the affected area using clean washcloths can help. Using over the counter benzoyl peroxide cleansers can also help control it. Care must be taken to rinse it off completely from skin to prevent bleaching of towels and clothing. Sometimes prescription antibiotic creams and solutions are needed for widespread infection or if conservative measures do not help. Rarely, oral antibiotics and antifungals are needed to control the infection or for severe types of folliculitis. If left untreated, folliculitis can cause large sores, and even scars.

Talk to your dermatologist if your condition is not responding to over the counter treatment options, or if the inflammation is severe. Timely treatment is important to prevent scarring.