Last month we reviewed superficial folliculitis. In this issue we cover deep folliculitis (see Table 1) and its many treatment modalities.
A furuncle forms from a hair follicle. It’s a walled-off collection of pus. Multiple adjacent furuncles is called a carbuncle. Lesions are often painful. Consider a swab for bacterial culture and sensitivity. Treatment often requires incision and drainage. Oral antibiotics are sometimes used to prevent spreading infection and recurrence.
In this common condition, inflammatory lesions occur due to tightly curled hairs that curve back into the skin. The hair penetrates the dermis and causes an inflammatory reaction. It’s seen more often in patients with type 6 (dark brown or black) skin. Locations typically affected in men include the beard and scalp. The groin is often affected in women who shave.
Clinically, lesions range from papules and pustules to abscesses. Hypertrophic scars and even keloids can develop, resulting in grooves that can hinder shaving. The diagnosis is often made clinically.
Patients should be educated about gentle shaving techniques and care to reduce ingrown hairs. A sharp clean razor, generous amounts of shaving cream, massage with warm water followed by cool compresses after shaving are all key. Discontinuing shaving can help with resolution of lesions, although up to 6 months may be needed for more severe cases.
Topical steroids combined with anti-inflammatory antibiotics can be helpful such as 2% clindamycin and 1% hydrocortisone lotion. These can be applied after shaving.
Anti-inflammatory systemic antibiotics may also be used for more extensive cases, such as tetracyclines. Laser hair removal can be very effective, although may not be appealing for all.
Acne keloidalis nuchae
Acne keloidalis nuchae (AKN) refers to a chronic papular or pustular eruption localized to the occipital area and the nape of the neck, resulting in keloid formation and occasionally scarring alopecia. Although AKN is most common in young adult men with darkly pigmented skin, cases have been described in Caucasians and occasionally in females. Early lesions are erythematous, firm papules, follicularly-based, found typically on the lower occiput. Sometimes, in more severe cases, lesions may extend from the occiput to the vertex and crown and may form large, hypertrophic scars. The presence of inflammatory papules, pustules and hypertrophic scar formation on the occipital scalp and posterior neck in a black male are pathognomic for AKN. Complications arise when hair follicles and shafts become embedded in connective tissue causing a foreign-body reaction, sinus tract formation and bacterial superinfection.
Close shaving of the hair has been postulated as a cause for AKN as well as rubbing by collars and picking by patients. Advise your patients to avoid these aggravating factors.
Treatment depends on the stage of presentation. Early disease (papules and pustules scattered across the posterior neck and occipital scalp) may be best managed by topical antiseptics or antibiotics (1% erythromycin or clindamycin). As hypertrophic scars form, topical or intralesional corticosteroids (triamcinolone may be beneficial. When scarring alopecia, hypertrophic scars and symptoms related to itch, pain and discharging sinuses are present, surgical treatment directed at removing the follicles in their entirety from the area is an option.
Hidradenitis suppurativa (HS) is a recurrent disease of skin containing apocrine glands (e.g. axillae, anogenital areas) characterized by a progression of asymptomatic nodules to inflamed, painful, deep-seated “boils” with draining sinus tracts, subsequent scarring and persistent suppuration. The disease can be debilitating for patients and is challenging to treat. Individuals may have the disease for years before seeking help.
Advise patients to maintain excellent hygiene including daily washes with antibacterial soap. They should minimize rubbing/friction of the affected areas, wear loose-fitting clothing and consider weight loss. Have them avoid excessive moisture (e.g. sweating) and encourage use of antiperspirants (e.g. topical aluminum chloride, absorbent powder). Reassure them that they’re not alone. Many treatment options exist and support groups are available.
Treatment of HS can be medical or surgical, depending on severity of lesions.
Current medical management strategies consist of antibiotic therapy, anti-androgen therapy and suppressing inflammation. Topical antibiotics mays be as effective as oral antibiotics and provide relief for some patients. Try topical clindamycin, or topical clindamycin with benzoyl peroxide applied twice daily.
Consider anti-androgen therapy in female patients who present with HS, regardless of their androgen profile.
Unlike in acne, oral retinoids are relatively ineffective in HS. Isolated lesions can respond to intralesional corticosteroid injection — triamcinolone (e.g. 5 mg/mL). However, patients will require monthly injections as new lesions appear. Anti-inflammatory therapy with targeted/biological medications such as TNF-alpha inhibitors may be the best medical treatment to date. Studies are currently underway. Surgical therapies are reserved for extensive disease not responding to medical therapy. Complete resection of all involved tissue followed by resurfacing with a graft or a flap can prevent recurrences. The more extensive the surgery, the less likely there will be recurrences.
John Kraft, MD, FRCPC is a dermatologist in private practice in Markham and Thunder Bay, ON.
Charles Lynde, MD, FRCPC is an assistant professor of dermatology at the University of Toronto.