Eczema Complications series – Folliculitis

This is a 4-topic series focused on complications from eczema and mainly inspired because my daughter recently had impetigo. Moreover, the potential complications from bacterial, viral and fungal infection are not very often emphasized yet a child with eczema is often vulnerable to infections. So let’s explore!

Bacterial Infection

Last week, we covered viral infections – eczema herpeticum previously covered in this blog (here and here) and molluscum contagiosum. This week, our focus is on bacterial infection. The most common bacteria that colonizes eczema skin is staphylococcus aureus bacteria, which is the cause of common children skin infections like impetigo and folliculitis. Apart from impetigo and folliculitis, S. aureus also causes other secondary infection with presence of pus, fever, swollen lymph nodes and in severe cases, staphylococcal scalded skin syndrome, where the lesions rupture to give scalded appearance (see this interview with Dr Clay Cockerell on symptoms of S.aureus infection).

Other bacterial infection include boils and ecthyma, also from S. aureus. The other common bacteria that causes infection is streptococcus pyogenes, which can cause cellulitis and erysipelas. Untreated bacterial infection can cause fatal systemic toxaemia or septicaemia, which is blood poisoning. If strep infection is a topic you’re interested, comment/email me and I may start a series on it!

Folliculitis

Folliculitis is an inflammation at the hair follicle that can be due to numerous causes – a common one being from staph bacteria. A word about staph bacteria is that even if it doesn’t trigger secondary infection, its presence impedes the recovery of eczema rash via (i) toxins (enterotoxin) from the bacteria that can trigger hypersensitivity and (ii) existing inflammation from bacteria makes it harder to treat the eczema (more on staph bacteria here).

So back to folliculitis – It appears as a small localized pus (on surface or deep) at the hair follicle, followed by red bump when the pus dried with surrounding inflamed skin that may itch. If the infection runs deep into the hair follicle, it can cause a boil which can be painful. The hair follicles on the chest, back, legs, face, neck, thighs and buttocks are more vulnerable to folliculitis. Folliculitis will not affect part of the body with no hair follicle such as the eye, mouth, palm and sole.

Multiple Causes of Folliculitis

Bacteria, from staphylococcus aureus is the most common cause.

Virus – Herpes simplex virus (that cause eczema herpeticum), herpes zoster (that cause shingles, read here of my daughter’s shingles experience) and molluscum contagiosum (covered last week) may also cause folliculitis.

Yeast – Folliculitis may also be from the yeast, Pityrosporum ovale (Malassezia) when it proliferates, usually on the trunk of young adults.

Fungi – Fungi such as tinea capitis (ringworm), Microsporum canis and Trichophyton tonsurans can cause folliculitis particularly on the scalp.

Parasite – Hair follicle mite (demodex) can affect the face or scalp of adults with compromised immune system or that of elderly. This is known as demodicosis. Scabies is another parasite that can trigger folliculitis.

Steroid – Systemically administered or topically applied steroids could result in facial folliculitis (perioral dermatitis) or steroid acne due to adverse reactions to long and significant doses of steroid.

Occlusion – Clothes with sweat, friction, thicker emollients, like paraffin-based ointment and adhesive plastic can break the skin and/or increase the penetration of bacteria into the hair follicle.

Chemicals – Some chemical like coal tar may cause irritant folliculitis.

Razor-burn folliculitis – This is due to frequent razor cuts creating opening on skin’s surface that allow bacteria to enter and cause inflammation at the hair follicle.  It is more common on women’s leg and men’s face and neck. Excessive close shaving creates trapped hair in the follicle, increasing inflammation.

Spa pool/ Hot tub folliculitis –  This is infection from inadequately chlorinated warm water, allowing the bacteria Pseudomonas aeruginosa to thrive. It is more common on the back and to prevent this, rinse/shower after a spa or hot tub.

Who is a Higher Risk of Folliculitis?

Skin conditions, such as acne, eczema and psoriasis patients

Diabetic patients

Obesity

Patients with lower immunity such as cancer, HIV, hepatitis or even chronic eczema patients who are on immunosuppressants may get eosinophilic folliculitis.

Occupations – Those that come into often contact with oil, tar or grease and sweat.

Warm and humid climate

Treatment of Folliculitis

The treatment will depend on the cause, as follow:

Bacteria – Antibacterial wash such as benzoyl peroxide, chlorhexidine or in certain case, antibiotics to kill the bacteria and clear the skin. There are increasing instances of methicillin-resistant Staph aureus bacteria, thus making it more difficult to treat such MRSA bacterial infection. Oral flucloxacillin is often prescribed and if there is penicillin resistance, erythromycin is prescribed. More on MRSA here.

Fungus and Yeast – Both fungus and yeast causing folliculitis can be treated using an antifungal shampoo or body wash such as ketoconazole (Nizoral shampoo) twice daily. Topical antifungal cream such as miconazole (Lotrimin) or terbinafine (Lamisil) and an antifungal medicine fluconazole (Diflucan) may be prescribed for more severe case.

Virus – Medication for virus, such as acyclovir for herpes simplex virus will help to resolve the folliculitis.

Razor folliculitis – Treatment includes antibacterial wash and topical antibiotics if not resolved on its own. Stopping to shave and using alternative hair removal techniques may help prevent future folliculitis from shaving repeatedly. Using a new razor and shaving in the direction of hair growth will help to prevent cuts. For men, antibacterial benzoyl peroxide shaving gel can be used. Permanent hair removal can also be attempted.

As the most likely factor is from bacterial infection, good hygiene measures such as hand-washing, not sharing towels/razors and showering after contact with likely bacteria surfaces helps prevent folliculitis. Not touching parts of body that have high staph bacteria such as the nose, armpit and perineum (area between anus and vulva/scrotum) can limit the spread of the bacteria to other parts of the body.

Folliculitis and Eczema

Children with eczema have a few factors to their disadvantage which make them more likely to get folliculitis. Of the causes of folliculitis, the one that most affect eczema patients is bacterial infection from staph bacteria.

1. Eczema skin already have higher likelihood of bacterial colonization, of more than 50% chance.
2. Most skin with staph bacteria won’t be harmed, however eczema skin is defective in its barrier protection, either from dry skin, ‘open’ skin from scratching and more permeable.
3. Eczema patients are suspected to be less able to fight common bacteria, fungus, virus and yeast.
4. The dry skin on eczema children is a more conducive environment for bacterial growth, compared to normal skin with natural oils.
5. The toxin produced by Staph aureus bacteria worsens the eczema with triggering more hypersensitive reaction/inflammation.

It once again points to keeping bacteria count low, proper hygiene, keeping our children fresh and cool as preventive measures for our children. What is your experience? Do share in the comment!