furunculosis

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Many types of skin infections can affect patients. Some, such as superficial fungal infections, are easily self-treated.However, bacterial infections, which include folliculitis, furuncles (boils) and carbuncles, are not amenable to self-treatment. They are caused by Staphylococcus aureus and generally require prescription therapy.

Folliculitis is the most superficial and easily treated of the three.[1] Minor cases sometimes resolve without treatment.Furuncles are deeper and in fact may develop as a result of improperly treated folliculitis. Failure to treat furuncles maylead to carbuncles.

Folliculitis is an inflammation of the hair follicles. It is more common in areas of the skin where short, coarse hair grows.The condition arises from an obstruction of the sebaceous gland associated with the follicle. Provoking factors includefriction from tight clothing, athletic padding, or shaving.[2] Folliculitis causes only minimal skin reddening, and, althoughthere may be some pain or itching, the patient seldom experiences extreme discomfort.[1] Because the inciting factor oftenoccurs over a fairly large patch of skin, groups of follicles are usually affected.

A crop of small pustules or papules may appear, each about 1 mm in width, and surrounded by a halo of erythema.[3]

Pharmacists may be able to differentiate folliculitis from various eczematous conditions by examining each lesion.Folliculitis lesions will be pierced by a hair, almost always directly in the center.

In infants and children, folliculitis preferentially affects the buttocks, face and axillae.[3] The legs are a common site inadolescent females who are beginning to shave. (If the patient usually shaves the affected area, it is helpful to stop doingso until the folliculitis resolves.) Adolescent males are likely to see the problem in flexural areas (areas that have to bendor flex, such as the elbows).[3]

Folliculitis also can be caused by the application of oils to the skin. For instance, mineral oil is found in certain topicalproducts, such as diaper rash oils and baby oils. It is a water barrier that eventually must be physically removed from theskin. If it is not, folliculitis could result.

For this reason, FDA-approved labeling suggests patients cleanse the skin before reapplication of mineral oil to preventaccumulation.Wax epilation, a method of hair removal, is another potential cause of folliculitis. The technique consists ofspreading heated wax over skin. After the wax has cooled somewhat, it is pulled away from the skin, removing hair thatwas trapped in the wax. Some patients experience adverse effects from this technique. In two cases, females notedsevere folliculitis presenting as a pustular rash beginning several days after epilation.[4] Systemic antibiotics and localantiseptics or steroids forced regression of the folliculitis, but both patients had residual keloid scars.

Folliculitis may be prevented by taking good care of the skin. This includes avoiding friction against the skin or otherprovoking factors such as wax epilation. Once a case of folliculitis has completely resolved, changing shaving methodsfrom a bladed razor to an electric razor may be helpful.[2] Further, the razor should not be pressed hard enough onto theskin to induce damage. The patient should shave in the direction of hair growth rather than against it.3 For maximalprevention, the patient should avoid tight-fitting and restrictive garments such as leotards, opting instead for loose clothingthat permits sweat to evaporate.

Consult Your Pharmacist - Bacterial Infectionsof the Hair FolliclesW. Steven Pray, Ph.D., R.Ph., Professor of Nonprescription Products and Devices, School

of Pharmacy, Southwestern Oklahoma State University, Weatherford, OKUS Pharmacist. 2000;25(4)

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Most cases of folliculitis are caused by Gram-positive organisms, such as Staphylococcus.[5] However, Gram-negativeorganisms, such as Klebsiella or Proteus, can cause folliculitis in patients who are given prolonged courses of antibiotictherapy for acne vulgaris.

Another recently recognized Gram-negative variant of standard folliculitis is "hot tub" or "spa pool" folliculitis. As the nameimplies, this form is caused by bathing in a hot tub used by a large group of people.[2] The cause is Pseudomonasaeruginosa, which is able to proliferate in the warm environment, especially if the water is poorly chlorinated. Pharmacistsmight recognize this problem by its characteristic distribution -- the lesions are confined to the areas on the legs, arms,buttocks and trunk that would be immersed in this type of device.[5] If this is the appearance, the pharmacist can inquireabout hot tub or spa pool exposure within the past six hours to three days. Other possible exposures include swimmingpools and contaminated loofah or synthetic sponges.[6,7] Even being in the water with a bath toy or bathtub plug that hasbecome blackened with a slimy-appearing residue has been implicated.[3] To confirm the diagnosis, a physician canculture the water or the pustules. Additional symptoms include low-grade fever, headache, dizziness, sore throat andeyes, and malaise.[6]

Furunculosis refers to a deep-seated infection of the hair follicle and is more commonly known as a boil.[5]

Predisposing factors to furuncles include carriage of Staphylococcus in the nares (nostrils), scabies, dermatitis thatproceeds to excoriation, diabetes mellitus, obesity, malnutrition, and administration of corticosteroids or cytotoxicagents.[5] Having had boils is a reliable predictor of future episodes, a condition known as recurrent furunculosis.

Patients cannot self-treat boils, which are located too deeply in the skin to be affected by topical application ofnonprescription creams/ointments. Self-treatment is also com-plicated by the problem of recognizing the condition as atrue furuncle; several conditions can masquerade as a boil. For instance, several papers describe U.S. residents who hadrecently visited Mexico or Central/South America, eventually developing a presumed furuncle.[8-10] The actual etiologywas the larva of the botfly (e.g., Dermatobia hominis). One suggested treatment for botfly infestation consists of applyingraw bacon to the lesion. After one hour, a small white feeding tube may protrude from the skin. With care, the white larvacan be teased from the skin by a physician. In no case is nonprescription therapy advisable.

Carbuncles are the result of neglected or mishandled lesions of furunculosis. If a patient ignores furuncles or manipulates,picks, or squeezes them, they extend laterally throughout the tissue, destroying the normal fibrous tissue walls andforming tunnel-like, interconnected abscesses.[5] Any type of trauma can extend the area of tissue affected, possiblyleading to severe sequelae such as septicemia, thrombophlebitis, and cellulitis.[2] Once again, patients with carbunclesmust be referred to a physician.

Skin infected with bacteria ideally should be covered until the infection has cleared. With impetigo, this helps preventspread of the infection. With carbuncles and furuncles (and, to a lesser extent, folliculitis), protection through use of adressing helps prevent trauma to the area.

For folliculitis, physicians may prescribe topical antibiotics such as clindamycin, erythromycin, or mupirocin. They may alsoprescribe oral antibiotics and culture exudate from the lesion to guide therapy. Ampicillin-clavulanic acid, minocycline, orerythromycin is usually suitable.[5]

Due to the fact that it resolves in a short period of time, "hot tub" folliculitis does not require therapy. However, carbunclesand furuncles are a different matter. Parenteral antibiotics that are not prone to beta-lactamase degradation (e.g.,cefazolin) may be recommended.[5] When the carbuncle or furuncle proceeds to develop its "point," the physician maycarefully lance it under sterile conditions and allow drainage.[5]

Sometimes the hair follicles become infected, especially in areas where short, coarse hair grows. This infection is known

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as folliculitis. It can occur on areas where you shave (face or legs) or where your skin rubs against tight clothing. The skinusually exhibits a crop of red bumps, which can be painful or itchy. Sometimes folliculitis will get better on its own, but if itdoes not, a visit to a doctor is required.

A boil (furuncle) is a reddened, painfully swollen area beneath the skin surface. Boils are caused by bacteria, usuallyStaphylococcus. Like folliculitis, a boil occurs in a hair follicle, but it becomes larger and is harder than the rather smallfolliculitis lesions. The hardness is caused by a large amount of material that collects beneath the skin. You should neversqueeze or try to open a boil with needles or razor blades. Doing so is extremely dangerous. You must see a doctor. Oralantibiotics are necessary to reach the deep skin layers where the boil is located. Ointments and creams containingantibiotics are not effective.

If a boil is neglected, and if there is another boil close to it, they may grow together underneath the skin surface to form themore serious skin problem known as the carbuncle. It is larger, more painful, and has several spots where it opens to theskin, draining a foul material. Again, patients cannot self-treat this condition, but must see a physician.

Impetigo is a bacterial infection of the skin caused by an organism known as Streptococcus and another known asStaphylococcus. Patients with impetigo may first notice a set of blisters, which break open, and then a yellowish crust mayform over the blister. Impetigo lesions are often found on the nose and mouth, but can infect other spots, such as ashaving wound or a scraped knee. Impetigo spreads easily from person to person, so an infected patient must be verycareful not to touch the affected areas and must get proper care immediately. Proper care requires seeing a physician.Never try to treat yourself with ointments such as Neosporin or Mycitracin. These products are absolutely unsafe forexisting skin infection and must not be used. If you put off proper care, the organisms that cause the condition can furtherdamage the body, for example, destroying a person's kidney function.

Diving Suit Folliculitis

[11] In both cases, the patients developed painful rashes the following day. Anti-Staphylococcal therapy was initiated inone patient. However, Pseudomonas aeruginosa was the culprit for both rashes, and the skin healed after appropriatetherapy. Pharmacists might question patients about recent wearing of a wet suit if the rash appears only on areas thatwould be covered by a wet suit. The etiology is identical to that of "hot tub folliculitis," in that the wet suit creates a moist,occlusive environment that predisposes skin to the growth of Pseudomonas aeruginosa.

Patient Information

There are several kinds of bacterial infections that can affect your skin, and they can be extremely unpleasant. Signs thatyour skin may be infected include: 1) the presence of heat in the skin, 2) reddening of the skin, 3) swelling, and 4) pain. Ifone or more of these signs are present, consult your pharmacist. He or she can help confirm whether an infection ispresent that requires you to see a doctor. Although there are numerous kinds of nonprescription antibiotic and antisepticsolutions, creams and ointments, they are only safe for preventing infection in minor cuts or burns. If your skin is alreadyinfected, these products are not to be used.

References

1. Eley CD, Gan VN. Folliculitis, furunculosis, and carbuncles. Arch Pediatr Adolesc Med. 1997;151:625-626.

2. Eiland G, Ridley D. Dermatological problems in the athlete. J Orthoped Sports Phys Ther. 1996;23:388-402.

3. Hogan P. What is folliculitis? Aust Fam Physician. 1998;27:528-529.

4. Mimouni-Bloc A, Metzker A, Mimouni M. Severe folliculitis with keloid scars induced by wax epilation in

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US Pharmacist. 2000;25(4) © 2000 Jobson Publishing

adolescents. Cutis. 1997;59:41-42.

5. Sadick NS. Current aspects of bacterial infections of the skin. Derm Clin. 1997;15:341-349.

6. Golledge CL. Skin rash from a tropical island. Aust Fam Physician. 1996;25:1167.

7. Kitamura M, Kawai S, HorioT. Pseudomonas aeruginosa folliculitis: A sporadic case from use of a contaminatedsponge. Br J Derm. 1998;139:359-360.

8. Anderson RN. An adult female with furuncles and formication. J Emerg Nurs. 1996;22:83-84.

9. Gewirtzman A, Rabinovitz H. Botfly infestation (myiasis) masquerading as furunculosis. Cutis. 1999;63:71-72.

10. Johnston M, Dickinson G. An unexpected surprise in a common boil. J Emerg Med. 196;14:779-781.

11. Saltzer KR, Schutzer PJ, Weinberg JM, et al. Diving suit dermatitis: A manifestation of Pseudomonas folliculitis.Cutis. 1997;59:245-246.

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