Folliculitis histology

Folliculitis histology DEFAULT

Special types of folliculitis which should be differentiated from acne

Kai-lv Sun and Jian-min Chang

Kai-lv Sun

Department of Dermatology, Beijing Hospital, National Center of Gerontology, Dongdan, Dongcheng District, Beijing, China

Find articles by Kai-lv Sun

Jian-min Chang

Department of Dermatology, Beijing Hospital, National Center of Gerontology, Dongdan, Dongcheng District, Beijing, China

Find articles by Jian-min Chang

Author informationArticle notesCopyright and License informationDisclaimer

Department of Dermatology, Beijing Hospital, National Center of Gerontology, Dongdan, Dongcheng District, Beijing, China

CONTACT Jian-min Chang [email protected], Department of Dermatology, Beijing Hospital, National Center of Gerontology, 1# Dahua Road, Dongdan, Dongcheng District, Beijing 100730, China

This paper is part of the special section based on the 3rd ICSGAD conference held in September 2016.

Received 2017 Apr 28; Accepted 2017 Jul 11.

Copyright © 2018 The Author(s). Published with license by Taylor & Francis

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

This article has been cited by other articles in PMC.


Because both acne vulgaris and folliculitis can present as inflammatory erythematous papules, pustules or nodules, they are often hard to distinguish. The importance to distinguish between these 2 shall be stressed as their pathogenesis and therapies are different and misdiagnosis or missed diagnosis may lead to improper treatment. We will introduce several special types of folliculitis that should be differentiated from acne to increase our knowledge of the disorders with an acne-like manifestation.

KEYWORDS: folliculitis, acne, differentiation


Acne vulgaris is a common and chronic cutaneous disorder that primarily affects face, chest and back of adolescents and young adults, which can thus result in multiple levels of psychological trauma. It is an inflammation of the pilosebaceous unit, which results from the proliferation of Propionibacterium acnes (P.acnes), and it can be presented as inflammatory papules, pustules, and nodules. Folliculitis refers to inflammation of the hair follicle, aroused by staphylococcus aureus (S.a) or other noninfectious factors. Follicular erythematous papules and follicular pustules on hair-bearing skin are a feature of superficial follicular inflammation. And the classic manifestation of deep folliculitis is nodules. Because of the similar clinical manifestation, it is often hard to distinguish acne vulgaris from folliculitis, and that can cause misdiagnose or missed diagnose, and thus delay correct treatment. Therefore, we need to understand and differentiate skin diseases with acne-like manifestation to help us with diagnosis and treatment. In this article, we introduce several special types of folliculitis which should be differentiated from acne, including superficial pustular folliculitis(SPF), folliculitis barbae and sycosis barbae, perifolliculitis capitis abscedens et suffodiens, folliculitis keloidalis nuchae, actinic folliculitis, eosinophilic pustular folliculitis (EPF), malassezia folliculitis and epidermal growth factor receptor(EGFR) inhibitor-induced papulopustular eruption.

Superficial pustular folliculitis

SPF, the result of inflammatory changes confined to the follicle orifice, is also known as follicular impetigo or Bockhart impetigo and is always caused by S.a. SPF is common on the scalp and limbs, but it can also be seen on the face, especially the perioral. The infection may secondarily arise from insect bites, scratches, or other skin injuries. Clinically, it manifests as pinhead-size, fragile, yellowish white, domed pustules (Fig. 1) with mild itching or burning. It develops in crops and heals in a few days without scar formation. Keeping the local area clean and topical antibiotics may be helpful.

Folliculitis barbae and sycosis barbae

Folliculitis barbae, a perifollicular chronic staphylococcal infection of the bearded area, is a medical term for persistent irritation caused by shaving and commonly occurs in men aged 20 to 40. It most frequently presents as superficial pustules pierced by hairs on an erythematous base and can be asymptomatic or painful and tender. If untreated the infection and inflammation can gradually progress leading to a more deeply seated infection known as sycosis barbae1(Fig. 2). An atrophic scar bordered by pustules and crusts may result in this case. Besides, in severe cases of sycosis, marginal blepharitis and conjunctivitis can be present. Topical antibiotics are the most commonly used treatments, while more extensive cases may require systemic antibiotics.

Perifolliculitis capitis abscedens et suffodiens

Perifolliculitis capitis abscedens et suffodiens, also known as dissecting cellulitis of the scalp (DCS) or Hoffman disease, is a chronic inflammatory disorder of the scalp characterized by fluctuating, interconnecting nodules (Fig. 3). It most commonly occurs in young men and is often associated with patchy hair loss.2 Secretion culture of bacteria and fungi is always negative but secondary infection can occur. Perifolliculitis capitis abscedens et suffodiens, acne conglobata, hidradenitis suppurativa are associated with a condition called follicular occlusion triad. Oral antibiotics and oral isotretinoin treatment are the main treatment methods.

Folliculitis keloidalis nuchae

Folliculitis keloidalis nuchae, also known as acne keloidalis, is a rare, idiopathic, inflammatory condition of the posterior neck. Occasionally, it extends onto the scalp. Approximately 90% of patients are males younger than 40 y old.3 It presents as follicular papules coalescing into plaque associated with fibrosis and keloid formation (Fig. 4). Control of the exacerbating factors such as rubbing, scratching or wearing high-collared shirts and topical corticosteroids/antibiotics may help. Surgery is sometimes required to manage the condition.

Actinic folliculitis

Actinic folliculitis, a rare photodermatosis, usually appear between 4 and 24 hours after exposure to sunlight.4 The mechanism by which exposure to ultraviolet light results in folliculitic lesions remains unclear. It is characterized by apruritic, erythematous, pustular eruption appearing over exposed positions such as cheeks, sides of neck, shoulders and arms (Fig. 5), which falls into the same spectrum as acne aestivalis and actinic superficial folliculitis, and should be differentiated from acne vulgaris aggravated by sunlight. Therapeutically, limiting sun exposure is necessary, and other treatments are similar to those used for acne vulgaris.

Eosinophilicpustular folliculitis

EPF is characterized by recurrent crops of sterile, intensely pruritic follicular papules and pustules with central clearing and peripheral extension (Fig. 6). Men are affected more frequently than women. In some special cases, this can also be seen in infants in a self-limited form.5 The most common areas of involvement are the face, back, and trunk. It is found primarily in HIV-positive patients, patients undergoing treatment of hematologic malignancies and bone marrow transplant recipients.6 To confirm the diagnosis, skin biopsy is needed. We can see infiltration of eosinophils and lymphocytes focused at the level of the follicular isthmus. And follicular eosinophilic abscesses may be observed. Treatment is difficult. High-potency or superpotent topical corticosteroids are the most effective treatment.

Malassezia folliculitis

Malassezia folliculitis, formerly known as pityrosporum folliculitis, is a fungal acneiform condition. More commonly occurred on males than in females, Malassezia folliculitis results from overgrowth of yeast present in the normal cutaneous flora.7 The eruptions often appear after sun exposure or antibiotic or immunosuppressive treatment.8 It is characterized by small, scattered, itchy, follicular papules that develop on the back, chest, posterior arms, and sometimes the neck, which slowly enlarge to become pustular (Fig. 7). Pruritus and lack of comedones differentiate the condition from acne vulgaris. Treatment with topical azole antifungal agents may be effective, but oral therapy with itraconazole is often necessary and results in rapid improvement.

EGFR inhibitor-induced papulopustular eruption

EGFR inhibitors such as gefitinib, cetuximab are increasingly used for the treatment of advanced lung, pancreatic, colorectal, and head and neck cancers.9 Because of the abundant expression of EGFR in the skin and adnexal structures, cutaneous adverse events including papulopustular eruptions are frequent.10 Usually, the onset of the eruption typically occurs 1–3 weeks after beginning treatment with an EGFR inhibitor. Patients present with an eruption of follicular pustules and papules over the seborrheic areas, such as the scalp, face, upper chest and back (Fig. 8). Multiple treatments have been tried including antibiotics, corticosteroids, and retinoids. Prophylaxis with oral doxycycline or minocycline may also be of benefit.


It's very important to study special types of folliculitis which can be differentiated from acne. It has helped us to diagnose and treat skin diseases with acne-like manifestation accurately and effectively. Besides the diseases we mentioned in this review, there are other acne-like skin disorders that should be noticed in the clinical practice.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.


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Continuing Education Activity

Folliculitis is a common skin condition that usually involves infection of the hair follicle. While this condition is typically benign, prompt recognition can aid in the improvement of quality of life of patients with this condition. This activity reviews the evaluation and treatment of folliculitis and highlights the role of the interprofessional health care team in evaluating and treating patients with this condition.


  • Outline the etiology of different forms of folliculitis.

  • Review common history and physical exam findings in patients with folliculitis.

  • Summarize the different treatment options for each listed type of folliculitis.

  • Explain the importance of collaboration and communication among the interprofessional team to enhance the delivery of care for patients affected by folliculitis.

Access free multiple choice questions on this topic.


Folliculitis is a common, generally benign, skin condition in which the hair follicle becomes infected/inflamed and forms a pustule or erythematous papule of overlying hair-covered skin. While this is a non-life threatening condition and in most cases is self-limited, it can present challenges for immunocompromised patients and in some cases progress to more severe diseases.[1]


Most commonly, folliculitis is caused by bacterial infection of the superficial or deep hair follicle. However, this condition may also be caused by fungal species, viruses and can even be noninfectious in nature. Several of the causative agents of folliculitis are listed below and include:

Superficial bacterial folliculitis – The most common form of folliculitis, this particular condition is usually caused by the bacteria Staphylococcus aureus. It should be noted that both the methicillin-sensitive and methicillin-resistant forms of this bacteria can cause folliculitis.[1]

Gram-negative bacterial folliculitis - Commonly referred to as “hot tub” folliculitis, this condition results from the bacteria pseudomonas aeruginosa. It typically arises after exposure to contaminated water from either an improperly treated swimming pool or hot tub. Other bacteria that may cause this condition include Klebsiella and Enterobacter. Folliculitis from these bacteria commonly arises after long-term use of oral antibiotics.[2][3]

Pityrosporum Folliculitis - This particular form of folliculitis is fungal, caused by the Malassezia species of fungi such as Malassezia furfur. Typically found in adolescence secondary to increased activity of their sebaceous glands, and is commonly found in a cape-like distribution over the patient’s shoulders, back, and neck. Clinical suspicion of this condition should arise in patients diagnosed with acne that has failed to respond or even worsened, after antibiotic treatment.[4] 

Viral folliculitis - Most commonly caused by herpes virus it could also be caused by Molluscum contagiosum, but this is far rarer. Folliculitis due to herpes virus presents in much the same way as bacterial folliculitis with the exception that papulovesicles and/or plaques are usually present and not pustules. Another key to the diagnosis of this condition is that lesions typically appear in either groups or clusters.[5]

Demodex folliculitis - a type of folliculitis caused by the mite Demodex folliculorum. This particular type of folliculitis is controversial as the Demodex mite normally presents in the pilonidal sebaceous area of the skin. Estimates are that 80 to 90% of all humans may carry this mite.[6] 

Eosinophilic folliculitis - This particular brand of folliculitis is found predominantly in those with advanced HIV or those with low CD4 counts.[7] Although a non-HIV variation of this condition has been seen as a rare side effect in patients undergoing chemotherapy.[8] While the exact etiology of this condition is unknown, studies suggest it could result from inflammatory disease secondary to immune dysregulation and that there may be an associated underlying infection.[9] Most commonly, this condition presents as erythematous and urticarial follicular papules, usually on the scalp, face, and neck with rare pustules.


While the precise incidence of folliculitis is not currently known, we do know that patients who have a history of diabetes, obesity, prolonged use of oral antibiotics, are immunosuppressed/immunocompromised or who shave frequently are at risk for developing this condition. While gender does not correlate with an increased incidence of folliculitis, there may be a correlation between the type of folliculitis and gender. For example, Malassezia folliculitis is commonly seen in men more than women.[4]


Most commonly, infection of the hair follicle is the mechanism behind most folliculitis cases. Even so, folliculitis may also result from fungal or viral infections, but this does not mean that all folliculitis cases are infectious. Sometimes, folliculitis may be the result of inflammation secondary to ingrown hairs as well as caused by certain drugs such as lithium and cyclosporine.


In the vast majority of cases of folliculitis, histopathology is not needed for diagnosis as this condition is a clinical diagnosis. However, in the case of eosinophilic folliculitis skin biopsy should be done for confirmation of the diagnosis. These biopsies would show perifollicular infiltrates that include lymphocytes and eosinophils predominantly around the area where the sebaceous gland and duct meet follicle. Uncommonly, the clinician may need to perform a skin biopsy to differentiate folliculitis from a condition that may mimic it. In cases of bacterial folliculitis, a biopsy would show a neutrophilic invasion of the hair follicle.

History and Physical

A complete history, as well as a focused physical exam, is usually enough to elucidate the diagnosis. Essential elements of history should include[10]:

  • Recent increase of scratching due to pruritus

  • History of increased sweating

  • Use of topical corticosteroids

  • Recent and/or long term use of oral antibiotics

  • Any hot tub and/or swimming pool exposure

  • History of HIV with CD4 count less than 250 or immunosuppression (ex. A patient who recently had a transplant that’s on immunosuppressive drugs)

Physical exam should include close inspection of hair-bearing areas, including the bilateral upper and lower extremities as well as the chest, back, face, and scalp. On exam, the clinician should look for small pustules in these areas with peri-follicular inflammation.


The diagnosis of folliculitis is clinical. In general, no diagnostic testing or radiographic evaluation is necessary to diagnose this condition in lieu of a thorough history and physical exam. A standard KOH preparation can be used to visualize hyphae and spores associated with folliculitis caused by Malassezia. KOH preparation could also be used to diagnose Demodex folliculitis; however, this is not common in clinical practice.[11][6] Also, a skin biopsy is usually required to confirm the diagnosis of eosinophilic folliculitis.

Treatment / Management

Staphylococcal folliculitis - most simple cases of staph folliculitis with few pustules will resolve spontaneously within a few days. However, for more extensive disease, topical antibiotics can be an option. First-line agents typically include topical mupirocin and clindamycin. Should these prove ineffective or should the patient present with deeper folliculitis such as furunculosis and carbunculosis or more extensive involvement of the skin, then oral antibiotics such as cephalexin and dicloxacillin are options.[12][13]

Gram-negative folliculitis - Much in the same way as staph folliculitis, simple cases will generally resolve spontaneously after 7 to 10 days with good skin hygiene. In certain cases where this is seen secondary to prolonged antibiotic use, oral antibiotic treatment that covers for pseudomonas are possible choices including ampicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin all being first-line agents.[14]

Pityrosporum Folliculitis - systemic therapy with oral antifungal agents, is often the treatment of choice for this condition. Although topical antifungals are an option, the belief is that systemic therapy can’t eliminate the Malassezia fungus deeper within the follicle than can topical therapies. Itraconazole and fluconazole are the two treatments of choice for this condition. Although there is more evidence for the effectiveness of itraconazole for treating this condition, fluconazole is often the treatment of choice secondary to its better side effect profile.[15] 

Viral folliculitis - folliculitis secondary to infection with herpes simplex virus may receive treatment in the same way as a normal outbreak of herpes with oral acyclovir, valacyclovir, and famciclovir. In the same way, folliculitis secondary to molluscum contagiosum infection may be treated the same as an outbreak of molluscum with either curettage or cryotherapy. Cantharidin is a topical agent that can be used to treat molluscum folliculitis. However, this drug is not available in the United States.[14]

Demodex Folliculitis – anti-parasitic agents, are the treatment of choice for this particular brand of folliculitis. Treatments such as topical permethrin as well as oral ivermectin and oral metronidazole are therapeutic options. One study found that dual therapy with oral ivermectin/oral metronidazole could be more effective than monotherapy of either drug alone. Although, topical permethrin 5% cream is usually the initial treatment of choice.[16][17]

Eosinophilic folliculitis - in general, the first-line treatment for this condition is antiretroviral therapy to treat the patient’s underlying HIV. In the vast majority of patients, treatment of the underlying HIV which show improvement or even resolution of this condition. Although some patients may have a flare of this condition during the first six months after ART initiation. In these cases, patients may be treated with optional therapies for a few weeks to months which include topical corticosteroids, antihistamines, phototherapy, and even itraconazole or isotretinoin.[18]

Differential Diagnosis

  • Acne vulgaris

  • Papulopustular rosacea

  • Drug-induced folliculitis

  • Hidradenitis suppurativa

  • Scabies

  • Pseudofolliculitis barbae

  • Keratosis pilaris

  • Acne keloidalis nuchae


As this condition is generally benign and often self-limiting, the outlook and prognosis are very good for a full recovery. With proper hygiene and management of any underlying conditions, recurrence rates can remain minimal.


  • Progression to a more severe skin condition such as cellulitis or abscess

  • Medication side effects (drug allergies or adverse drug-drug interactions)

Deterrence and Patient Education

In the vast majority cases of folliculitis, the only therapy needed is time, as most cases will resolve spontaneously. More severe cases can be managed medically with either antibiotic, antifungal, or anti-parasitic agents. Patients should be counseled on proper hygiene for the affected area as well as the use of warm compresses several times daily for up to 15 minutes on the affected area. Patients should also receive counsel against scratching or shaving the affected areas as this could cause increased irritation and could potentially spread the causative agent.

Enhancing Healthcare Team Outcomes

Folliculitis is a very common condition that can easily be identified by all members of the healthcare team, including primary care physicians, nurse practitioners, physician assistants, and nursing staff. All of these individuals can play essential roles in the diagnosis and patient education of this condition.

Proper hygiene is of paramount importance to prevent recurrence as well as to facilitate the resolution of this condition. In more severe cases, medical therapy may be necessary. In these cases, the local pharmacist can be consulted to help determine correct coverage for the underlying causative agent for these patients. However, most cases of folliculitis are self-limiting and will resolve on their own with proper home care.

Should these cases prove to be too extensive, do not resolve on their own, or don’t resolve after medical management referral to a dermatologist is recommended. A pharmacist can also offer a consult on two fronts; they can verify whether the patient's medication regimen has any drugs that could result in folliculitis, and they can also assist in agent selection, antimicrobial coverage assessment, and perform additional patient counseling. Nursing must also have involvement, including monitoring for treatment effectiveness, counseling on the application of topical agents, and looking for signs of adverse drug reactions. While folliculitis is a generally benign, self-limiting condition, this does not preclude the involvement of an interprofessional team approach to diagnosis and management, resulting in better patient outcomes. [Level V]

Folliculitis Keloidalis


Folliculitis Keloidalis. Contributed by DermNetNZ



Folliculitis. Contributed by DermNetNZ

Malassezia folliculitis - small, erythematous papules and pustules


Malassezia folliculitis - small, erythematous papules and pustules. Contributed by and used with permission from

Folliculitis post shaving


Folliculitis post shaving. Contributed by Dr. Shyam Verma, MBBS, DVD, FRCP, FAAD, Vadodara, India



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Malassezia folliculitis pathology

HomeTopics A–ZMalassezia folliculitis pathology

Author: Assoc Prof Patrick Emanuel, Dermatopathologist, Auckland, New Zealand, 2014.

Malassezia folliculitis pathology — codes and concepts

Malassezia folliculitis is likely caused by Malassezia globosa in the majority of cases. Follicularocclusion may be the primarypathology. Overgrowth of yeast probably follows as a secondary process.

Histology of malassezia folliculitis

The follicles are often plugged but there is minimal other epidermal change. There is a suppurative folliculitis, primarily involving the infundibular portions of the hairfollicle (figures 1, 2, 3 show the same process at progressively higher magnification). PAS stain reveals numerous oval yeast-like organisms within the follicle and often in the surrounding dermis (figure 1, inset). The yeasts have been compared to a “clown with clown nose” as there is often small budding of the yeast-like forms (figure 1, arrow). The surrounding dermis shows a reactive inflammatory reaction which may be exuberant if there is follicular rupture.

Malassezia folliculitis pathology

Special studies for malassezia folliculitis

PAS or GMS is typically required to demonstrate the malassezia yeast. The morphology of the organism can be seen in figure 1.

Differential diagnosis of malassezia folliculitis pathology

Bacterial folliculitis – Morphologically identical, but without the causative organisms. Malassezia folliculitis is likely under-diagnosed as it will only be recognised if stains are done on all cases of suppurative folliculitis

Majocci granuloma – Rather than yeast-like forms, dermatophytes will be seen within follicular structures with special stains. The process is typically a deep folliculitis rather than the superficial process seen with malassezia folliculitis.

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Folliculitis, Causes, Signs and Symptoms, Diagnosis and Treatment.

Eosinophilic pustular folliculitis pathology

HomeTopics A–ZEosinophilic pustular folliculitis pathology

Authors: Dr Achala Liyanage, Dermatology Fellow, Waikato Hospital, Hamilton, New Zealand; Assoc Prof Patrick Emanuel, Dermatopathologist, Auckland, New Zealand; Chief Editor: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, January 2015.

Eosinophilic pustular folliculitis pathology — codes and concepts


Eosinophilicpustular folliculitis is a heterogeneous group of disorders consists of clinical subsets including classic Ofuji disease, HIV-associated, paediatric, cancer, and medication-associated eosinophilic pustular folliculitis. All have a similar histological appearance.

Histology of eosinophilic pustular folliculitis

In eosinophilic pustular folliculitis, there is eosinophilic spongiosis and pustulosis involving the infundibular region of the hairfollicle. The follicular architecture is usually preserved. There can be minimal numbers of neutrophils or mononuclear cells within the infiltrate.

Eosinophilic pustular folliculitis pathology

Images provided by Dr Duncan Lamont, Waikato Hospital

Special studies in eosinophilic pustular folliculitis

PAS or silver methenamine preparation should always be examined to exclude dermatophyte infections.

Differential diagnosis to eosinophilic pustular folliculitis

Dermatophyte infection

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  • Weedon’s Skin Pathology (Third edition, 2010). David Weedon

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Histology folliculitis

After that, she smiled, put on my robe and left the bathroom. For some more time I lay content and exhausted. Suddenly, restless thoughts began to overwhelm me, as if they had taken advantage of me, because in fact she achieved what she wanted in 2 counts, came to the capital and.

What is Folliculitis -- Folliculitis : Causes, Symptoms and Treatment

Irina twisted and wriggled beneath me, whimpering softly with voluptuousness. Taking her by the hips, I parted my legs and saw the secret that women hide from. Men. Gently kissed the lips of the delicate flower, I parted them and saw the pulsing reddish flesh. Having clung to them, I began to drive my tongue trying to reach deeper.

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And then I'll jerk off and end on her. it will be necessary to take off her sweater and bra, which already almost on her head, otherwise she will start to fuss completely afterwards. No, she will be at a loss as to why we are naked. Yes, and the bed is not spread out, and where is her here that. I do not know.

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