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of Rheumatology criteria and the development of alternative criteria. Arthritis

Care Res (Hoboken). 2014;66(9):1364–1373.

3.National Guideline Clearinghouse. Guideline summary NGC-7367: management of fibromyalgia syndrome in adults. http://f.i- md.com/medinfo/material/8d0/4eb2854244ae46d1d13648d0/4eb2855d44ae46 Accessed September 4, 2017.

4.Häuser W, Petzke F, Üçeyler N, et al. Comparative efficacy and acceptability of amitriptyline, duloxetine and milnacipran in fibromyalgia syndrome: a systematic review with meta-analysis. Rheumatology (Oxford). 2011;50(3):532–543.

5.Häuser W, Walitt B, Fitzcharles MA, et al. Review of pharmacological therapies in fibromyalgia syndrome. Arthritis Res Ther. 2014;16(1):201.

6.Affaitati G, Costantini R, Fabrizio A, et al. Effects of treatment of peripheral pain generators in fibromyalgia patients. Eur J Pain. 2011;15(1):61–69.

ADDITIONALREADING

Theadom A, Cropley M, Smith HE, et al. Mind and body therapy for fibromyalgia. Cochrane Database Syst Rev. 2015;(4):CD001980.

SEE ALSO

Algorithm: Fatigue

CODES

ICD10

M79.7 Fibromyalgia

CLINICALPEARLS

Use ACR criteria to make the formal diagnosis.

Fibromyalgia is not a somatoform disorder and is not merely a manifestation of depression or anxiety. As with all chronic pain syndromes, fibromyalgia is frequently associated with mood and anxiety disorders.

The best clinical outcomes occur in patients who understand their illness and actively engage in a multimodal treatment plan that includes exercise, sleep

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hygiene, judicious medication use, CBT, and lifestyle modifications.

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FOLLICULITIS

David L. Anderson, MD

BASICS

DESCRIPTION

Superficial inflammation of a follicle, usually a hair follicle, caused by infection, local trauma, or chemical irritation (1)

Can occur anywhere on the body where hair is found

Most frequent symptom is pruritus.

Painless or tender pustules, vesicles, or pink/red papulopustules up to 5 mm in size

Most commonly infectious in etiology:

–Staphylococcus aureus bacteria (most common)

–Pseudomonas aeruginosa infects areas of the body exposed to poorly chlorinated hot tubs, pools, or contaminated water.

–Aeromonas hydrophila with recreational water exposure

–Fungal (dermatophytic, Pityrosporum, Candida)

–Viral (VZV, herpes simplex virus [HSV])

–Parasitic (Demodex spp. mites, schistosomes)

Noninfectious types

–Acneiform folliculitis

–Actinic superficial folliculitis

–Acne vulgaris

–Keloidal folliculitis

–Folliculitis decalvans

–Perioral dermatitis

–Rosacea

–Fox-Fordyce disease

–Pruritus folliculitis of pregnancy

–Eosinophilic pustular folliculitis (three variants: Ofuji disease in patients of Asian descent, HIV-positive/immunocompromised, infantile)

–Toxic erythema of the newborn

–Eosinophilic folliculitis (seen in HIV-positive/immunocompromised)

–Follicular mucinosis

Skin disorders may produce a follicular eruption that includes the following:

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–Pseudofolliculitis: similar in appearance; occurs after shaving; affects the face, scalp, pubis, and legs. Pseudofolliculitis barbae, or razor bumps, occurs frequently in black men.

–Atopic dermatitis

–Follicular psoriasis

EPIDEMIOLOGY

Affects persons of all ages, gender, and race

ETIOLOGYAND PATHOPHYSIOLOGY

Predisposing factors to folliculitis

Chronic staphylococcal carrier

Diabetes mellitus

Malnutrition

Pruritic skin disease (e.g., scabies, eczema)

Exposure to poorly chlorinated swimming pools/hot tubs or water contaminated with P. aeruginosa, A. hydrophila, or schistosomes

Occlusive corticosteroid use (for multiple hours) Bacteria

–Superficial or deep

–Most frequently due to S. aureus (increasing number of methicillin-resistant S. aureus [MRSA] cases)

–Also due to Streptococcus species, Pseudomonas (following exposure to water contaminated with the species), or Proteus

–May progress to furunculosis (painful pustular nodule with central necrosis

that leaves a permanent scar after healing) Fungal

–Dermatophytic (tinea capitis, corporis, pedis)

–Pityrosporum (Pityrosporum orbiculare) commonly affecting teenagers and men, predominantly on upper chest and back

–Candida albicans, although rare, has been reported with broad-spectrum antibiotic use, glucocorticoid use, immunosuppression, and in those who abuse heroin, resulting in candidemia that leads to pustules and nodules in hair-bearing areas.

Viral

–HSV

–May be due to molluscum contagiosum, usually a sign of immunosuppression

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Parasitic

–Demodex spp. mites (most commonly Demodex folliculorum)

–Schistosomes (swimmer’s itch)

Acneiform type commonly drug-induced (systemic and topical corticosteroids, lithium, isoniazid, rifampin), EGFR inhibitors

Severe vitamin C deficiency

Actinic superficial type occurs within 24 to 48 hours of exposure to the sun, resulting in multiple follicular pustules on the shoulders, trunk, and arms.

Acne vulgaris

Keloidal folliculitis is a chronic condition affecting mostly black patients; involves the neck and occipital scalp, resulting in hypertrophic scars and hair loss; usually secondary to folliculitis barbae from shaving

Folliculitis decalvans is a chronic folliculitis that leads to progressive scarring and alopecia of the scalp.

Rosacea consists of papules, pustules, and/or telangiectasias of the face; individuals are genetically predisposed. Helicobacter pylori and D. folliculorum have also been implicated.

Perioral dermatitis seen most commonly in children and young women; restricted to the perioral region as well as the lower eyelids; may be due to cosmetics, hyperandrogenemia, or use of fluorinated topical corticosteroids

– Typically spares vermilion border

Fox-Fordyce disease affects the skin containing apocrine sweat glands (i.e., axillae), resulting in chronic pruritic, annular, follicular papules.

Eosinophilic pustular folliculitis has three variants: classic (Ofuji disease), associated with HIV infection, and infantile.

Toxic erythema of the newborn is a self-limiting pustular eruption usually appearing during the first 3 to 4 days of life and subsequently fading in the following 2 weeks.

Malassezia infections in adult males with lesions on trunk (2)

RISK FACTORS

Hair removal (shaving, plucking, waxing, epilating agents)

Other pruritic skin conditions: eczema, scabies

Occlusive dressing or clothing

Personal carrier or contact with MRSA-infected persons

Diabetes mellitus

Immunosuppression (medications, chemotherapy, HIV)

Use of hot tubs or saunas Use of EGFR inhibitors

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Chronic antibiotic use (gram-negative folliculitis)

GENERALPREVENTION

Good hygiene practices

–Wash hands frequently.

–Antimicrobial soap

–Wash towels, clothes, and linens frequently with hot water to avoid reinfection.

Good hair removal practices

–Exfoliate beforehand.

–Use witch hazel, alcohol, or Tend Skin afterward.

–Shave in direction of hair growth; use moisturizer/warm water.

–Decrease frequency of shaving.

–Use clippers primarily or single-blade razors if straight shaving is desired.

COMMONLYASSOCIATED CONDITIONS

Impetigo

Furunculosis

Scabies

Acne

Follicular psoriasis Eczema

DIAGNOSIS

HISTORY

Recent use of hot tubs, swimming pools, topical corticosteroids, certain hair styling and shaving practices, antibiotics or systemic steroids

HIV status

History of STDs (specifically syphilis)

MRSAexposures/carrier status

Ask about home and work environment (risk/exposure potential).

Pityrosporum folliculitis occurs more often in warm, moist climates.

Inquire about the timeline in which the lesions have occurred, including previous similar episodes.

PHYSICALEXAM

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Characteristic lesions are 1- to 5-mm–wide vesicles, pustules, or papulopustules with surrounding erythema.

Rash occurs on hair-bearing skin, especially the face (beard), proximal limbs, scalp, and pubis.

Pseudomonal folliculitis appears as a widespread rash, mainly on the trunk and limbs.

In pseudofolliculitis, the growing hair curls around and penetrates the skin at shaved areas.

DIFFERENTIALDIAGNOSIS

Acne vulgaris/acneiform eruptions

Arthropod bite

Contact dermatitis

Cutaneous candidiasis

Milia

Atopic dermatitis

Follicular psoriasis

Hidradenitis suppurativa

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Diagnosis is usually made clinically, taking risk factors, history, and location of lesion into account.

Culture and Gram stain of the pustule by scraping the pustule with a no. 15 blade and not directly swabbing the skin to identify infectious agent and sensitivities to antibiotics

KOH preparation as well as Wood lamp fluorescence to identify Candida or yeast

Tzanck smear where suspicion of herpetic simplex viral folliculitis is high

Follow-Up Tests & Special Considerations

If risk factors or clinical suspicion exist, consider serologies for HIV or syphilis.

If recurrent, consider HIV testing and A1C/fasting blood sugar testing to evaluate for diabetes.

Punch biopsy may be considered if lesions persist despite treatment (3)[C].

Test Interpretation

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Treat positive bacterial culture according to sensitivities.

Positive HIV serology: Follow up with CD4 count and punch biopsy to rule out eosinophilic folliculitis.

Eosinophilic folliculitis: Collect eosinophils within superficial follicle (4).

TREATMENT

GENERALMEASURES

Lesions usually resolve spontaneously.

Avoid shaving and waxing affected areas (5)[C].

Warm compresses may be applied TID.

Systemic antibiotics are typically unnecessary.

Topical mupirocin may be used in presumed S. aureus infection.

Topical antifungals for fungal folliculitis (2)[B] Preventive measures are keys to avoidance of recurrence:

–Antibacterial soaps (Dial soap, chlorhexidine, or benzoyl peroxide wash when showering/bathing)

–Bleach baths (1/2 cup of 6% bleach per standard bathtub, and soak for 5 to 15 minutes followed by water rinse 1 to 2 times a week)

–Keep skin intact; daily skin care with noncomedogenic moisturizers; avoid scratching.

–Clean shaving instruments daily or use disposable razor, disposing after 1 use.

–Change washcloths, towels, and sheets daily.

MEDICATION

Antiseptic and supportive care is usually enough. Systemic antibiotics may be used with questionable efficacy.

First Line

Staphylococcal folliculitis

–Mupirocin ointment applied TID for 10 days

–Cephalosporin (cephalexin): 250 to 500 mg PO QID for 7 to 10 days

–Dicloxacillin: 250 to 500 mg PO QID for 7 to 10 days

For MRSA

–Bactrim DS: 1 to 2 tablets (160 mg/800 mg) BID PO for 5 to 10 days

–Clindamycin: 300 mg PO TID for 10 to 14 days

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–Minocycline: 200 mg PO initially and then 100 mg BID for 5 to 10 days

–Doxycycline: 50 to 100 mg PO BID for 5 to 10 days

Pseudomonas folliculitis

–Topical dilute acetic acid baths

–Ciprofloxacin: 500 to 750 mg PO BID for 7 to 14 days only if patient is immunocompromised or lesions are persistent

Eosinophilic folliculitis/eosinophilic pustular folliculitis

–HAART treatment for HIV-positive–related causes

–Topical corticosteroids: betamethasone 0.1% BID for 3 to 24 weeks or

–Antihistamines (hydroxyzine, cetirizine) or

–Tacrolimus topically BID for 3 to 24 weeks or

–Isotretinoin 0.5 mg/kg/day PO for 4 to 8 weeks or

–Itraconazole or metronidazole

Fungal folliculitis

–Topical antifungals: ketoconazole 2% cream or shampoo or selenium sulfide shampoo daily or

–Econazole cream applied to affected area BID for 2 to 3 weeks

Systemic antifungals for relapses fluconazole (100 to 200 mg/day for 3

weeks) or itraconazole (200 mg/day for 1 to 3 weeks)

Griseofulvin (tinea capitis in children; 10 to 20 mg/kg/day for 6 weeks minimum)

Parasitic folliculitis

–5% permethrin: Apply to affected area, leave on for 8 hours, and wash off.

–Ivermectin: 200 µg/kg × 1 followed by topical permethrin

Herpetic folliculitis

–Valacyclovir: 500 mg PO TID for 5 to 10 days or

–Famciclovir: 500 mg PO TID for 5 to 10 days or

–Acyclovir: 200 mg PO 5 times daily for 5 to 10 days

ISSUES FOR REFERRAL

Unusual or persistent cases should be biopsied and then referred to dermatology.

ADDITIONALTHERAPIES

Public Health Measures

Outbreaks of culture-positive Pseudomonas hot tub folliculitis should be reported so that source identification can be determined and superchlorination (14 parts/million) can occur.

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SURGERY/OTHER PROCEDURES

Incision and drainage is unlikely to be necessary and typically not preferred due to potential for scar formation.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Resistant cases should be followed every 2 weeks until cleared.

One return visit in 2 weeks if symptoms abate

DIET

For obese patients, weight reduction will decrease skin-on-skin friction.

PATIENT EDUCATION

Avoid shaving in involved areas.

PROGNOSIS

Usually resolves with treatment; however, S. aureus carriers may experience recurrences.

Mupirocin nasal treatment for carrier status and for family/household members might be helpful.

Resistant or severe cases may warrant testing for diabetes mellitus or immunodeficiency (HIV) (3)[C].

COMPLICATIONS

Primary complication is recurrent folliculitis.

Extensive scarring with hyperpigmentation

Progression to furunculosis or abscesses

REFERENCES

1.Breitkopf T, Leung G, Yu M, et al. The basic science of hair biology: what are the causal mechanisms for the disordered hair follicle? Dermatol Clin. 2013;31(1):1–19.

2.Song HS, Kim SK, Kim YC. Comparison between Malassezia folliculitis and

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