Folliculitis and pseudofolliculitis — Rapid

Synopsis

Separate infectious folliculitis from ingrown-hair inflammation, recognise organism and exposure clues, sample selectively, modify hair-removal technique and reserve antimicrobials for a defensible infectious target.

Folliculitis describes follicle-centred inflammation; determine whether the driver is bacterial infection, yeast, water exposure, occlusion, medicine, friction or an ingrowing hair before prescribing.
Pseudofolliculitis is a sterile foreign-body reaction to a cut hair re-entering skin and is common with tightly curled or coarse hair, especially after close shaving, waxing or plucking.
Visible or palpable ingrown hairs, papules aligned with the shaved area and post-inflammatory pigment change support pseudofolliculitis rather than bacterial infection.
Small monomorphic pustules centred on hairs can be staphylococcal folliculitis; obtain a fresh pustule swab when disease is recurrent, extensive, treatment-resistant or accompanied by household transmission.
Abrupt follicular pustules after a poorly maintained hot tub suggest Pseudomonas and often settle without antibiotics in an otherwise well person.
Itchy monomorphic upper-trunk papules or pustules, often after heat, occlusion or antibiotics, suggest Malassezia folliculitis and will not improve with antibacterial escalation.
Stopping close hair removal for four to six weeks is the most effective pseudofolliculitis intervention; if hair removal continues, use guarded clippers, leave short stubble and avoid stretching or repeated passes.
Persistent pigment or keloid scarring deserves active prevention and dermatology input; it is not evidence that a bacterial infection remains.

Key red flags

Fever, hypotension, rapidly spreading cellulitis, disproportionate pain, perineal necrosis, orbital or central-facial extension, immunosuppression with progression, grouped vesicles near the eye or a fluctuant abscess requires urgent assessment.

Invasive infection

Spreading warmth or colour change, rapidly increasing pain, fever, hypotension, fluctuance or necrosis signals cellulitis, abscess or deeper infection requiring urgent management.

Investigation priorities

Hair-removal and exposure historyFirst step

Separate ingrowing-hair inflammation from infectious, water-associated, occlusive and medicine-related causes.

Management branches

PseudofolliculitisRelease the close-shaving trigger

Papules with ingrown hairs follow shaving, plucking or waxing without spreading infection.

Explain the sterile foreign-body mechanism and, where feasible, stop close hair removal for four to six weeks while treating any confirmed superinfection separately.
If removal must continue, use guarded electric clippers leaving short stubble, soften hair, shave with the grain without stretching skin, make one light pass and clean equipment.
Consider a non-antibiotic keratolytic or retinoid approach off label for persistent papules, and refer scarring or occupationally intractable disease for laser-hair-reduction discussion with skin-tone expertise.

Key medicines

Mupirocin 2% ointmentApply a small amount to the affected area two to three times daily for up to ten days, using a dressing only if clinically appropriate.Avoid prolonged or repeated use, eyes and mucosa; stop for sensitisation, consider resistance and polyethylene-glycol absorption over large damaged areas or in renal impairment.

Adapalene 0.1% with benzoyl peroxide 2.5% gelApply a thin film once daily in the evening to affected hair-bearing skin as an off-label pseudofolliculitis strategy, introducing alternate-day or short-contact use if sensitive.Explain off-label use; contraindicated in pregnancy and pregnancy planning, avoid mucosa and freshly shaved or broken skin, manage irritation and warn about fabric bleaching.

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