Folliculitis and related conditions

Folliculitis is an acute pustular infection of multiple hair follicles. A furuncle or boil is a localised acute abscess formed in hair follicles next to each other and a carbuncle is a deep abscess of the skin and subcutaneous tissue formed in a group of follicles which is painful. Anything which tends to increase the numbers of skin surface bacteria may lead to the develop ment of folliculitis (Resnick, 2000) and this can include occlusion, overhydration and maceration. Folliculitis is more common in tropical climates and in those who live in overcrowded conditions or practice poor hygiene. It is also more common in patients who are obese, have diabetes mellitus or wear tight occlusive clothing.

Follicular pustules occur in hair bearing areas such as the legs, face, buttocks and groin. In women it can happen after hair removal by shaving or waxing and in men it can affect the beard area. It is usually, but not always, caused by S. aureus. Boils appear as tender, red pustules which grow over a few days into a large red lump under the skin surface. It may burst through the skin releasing pus or may gradually settle without bursting. They often occur on the face, neck, scalp, axillae and perineum as the bacteria survives best in moist areas. They can recur. Large boils or carbuncles can result in systemic illness.

Furuncles, carbuncles and other abscesses appear to be the most frequently reported clinical manifestations of MRSA (Nathwani et al., 2008).

1. Swabs should be taken for bacterial culture from the lesion only if: furuncles or boils are recurrent, there is a history of spread in the family or close contacts, the infection is severe or MRSA is suspected (Nathwani et al., 2008).
2. Acute staphylococcal infections should be treated with antibiotics in either topical or systemic forms.
3. Furuncles and carbuncles can be treated surgically by lancing or incision and drainage if they are <5 cm in diameter (Gould et al., 2009), and if cellulitis is not present antibiotics may not be required.
4. Recurrent and chronic cases are more difficult to treat and measures to help break the cycle of infection are needed (BAD, 2007). Antiseptic washes, for example iodine or chlorhexidine, can be used. Nasal carriage of staphylococcus should be treated with topical antibiotic, e.g. Mupirocin.
5. Other family members should be swabbed and if carriers should also be treated.
6. Hands and finger nails should be kept clean and short and clothing washed frequently using a hot wash.
7. Obese patients should be advised about the need to lose weight to reduce the survival of bacteria in the skin folds.