Scalp Folliculitis: Causes, Symptoms, Types and Treatment RichFeel

Scalp Folliculitis refers to an infection of scalp hair follicle. The infection can be caused either by bacteria, viruses, or fungi. In any case the inflamed hair follicle presents as a small red bump around the hair root. Scalp Folliculitis is not a chronic or life threatening condition. However, once the red pimple like bump turns into hard crust it can lead to severe discomfort and embarrassment. People also complain of pain and itching at the site of inflammation. Superficial Scalp Folliculitis affects only the upper part whereas the deep Scalp Folliculitis causes inflammation goes deeper in the hair follicles. Severe cases of Scalp Folliculitis can lead to hair loss and scarring of the hair follicles. This article explains the symptoms, causes and treatment option for Scalp Folliculitis.

What is Scalp Folliculitis?

Scalp Folliculitis is an inflammatory condition of scalp in which the hair follicles get inflamed following an infection. Clinically it is defined as presence of inflammatory cells within the wall and ostia of the hair follicle, creating a follicular-based pustule. The microorganisms causing Scalp Folliculitis   infection include bacteria like staphylococcus aureus and pseudomonas, or fungi like dermtophytes and Pityrosporum folliculate, and viruses like mulloscum contangiosum and herpes simplex. The inflamed scalp hair follicles present as   small pustules that appear like acne or pimple with white head. The inflamed follicles get very itchy and painful. Scalp Folliculitis   gets very troublesome especially when the red pustules appear on the frontal hairline. Scalp Folliculitis   is often associated with acne and it also responds to the therapy used for treatment of acne vulgaris. The acne causing bacteria Propionibacterium acnes is also thought to be responsible for causing infection and inflammation of the scalp hair follicle.

What is the cause of Scalp Folliculitis?

The exact etiology and causes of Scalp Folliculitis is not known. However, experts believe that Scalp Folliculitis is caused due to inflammation of hair follicles mainly following a microbial infection. The infection causing microorganisms include,

Bacteria: Propionibacterium acnes, Cutibacterium acnes, Staphylococcus aureus and pseudomonas  

Yeast or Fungi: Malassezia species, Dermtophytes and Pityrosporum folliculate  

Mites: Demodex folliculorum

Viruses: Mulloscum contangiosum and Herpes simplex

Although infection is the main cause of Scalp Folliculitis, other factors that irritate the scalp skin and increase the likelihood of hair follicle infection are also considered as contributing factors to development of Scalp Folliculitis .The other external factors that could increase the risk of Scalp Folliculitis include,

  • Excessive use of hair cosmetics such as hair oils, styling products, shampoos, etc. that could irritate the skin of scalp and cause inflammation.
  • Using public swimming pools or sharing other hygiene items that are not clean
  • Having an injury such as cuts or bruises on scalp which could get infected and further spread to hair follicles
  • Illnesses that lower immune power of the body. E.g. Cancer or HIV infection

What are the Risk Factors for Scalp Folliculitis?

Scalp Folliculitis   can affect anyone; however, certain factors make one individual more susceptible to infections over other. Since scalp has the maximum number of hair follicles, it is the most common site for Folliculitis. Men who have thick beard also are at risk of having Folliculitis of hair. Following are some risk factors that increase the chances of developing Scalp Folliculitis 

  • Having acne breakouts
  • Male gender
  • Having thick and curly hair especially in men
  • Wearing tight caps or scarfs that increase sweating on the scalp, wearing helmets for long time
  • Inflammation of scalp skin and hair follicles occurring due to frequent shaving

What are the Symptoms?

Scalp Folliculitis commonly occurs as a superficial infection where the upper portion of hair follicles gets inflamed and infected. However, in more serious forms of Scalp Folliculitis the infection goes to the deeper portion of the hair follicle. Severe Scalp Folliculitis   is usually more symptomatic and may cause scarring of the hair follicle resulting in loss of hair on the scalp. The deep Folliculitis lesions are usually accompanied by perifollicular inflammation, followed by follicular rupture (periFolliculitis ) and resulting abscess.

Typical symptoms of Scalp Folliculitis include,

  • Numerous red bumps that look like pimples near the hair roots
  • Pus-filled blisters around hair follicles
  • Itchiness and constant scratching on the scalp skin
  • Loss of hair in severe form of Scalp Folliculitis
  • Formation of crusts on the red pustules
  • Clusters of small red bumps on the scalp that get painful
  • Receding hairline especially when the pustules are formed along the hairline
  • Rupture of pustules casing abscess in severe deep Scalp Folliculitis

How is Folliculitis Diagnosed?

As with any other hair or scalp condition, the diagnosis of Scalp Folliculitis   begins with careful examination of scalp and hair. The doctor examines the appearance of red spots and pustules at the base of hair. Your medical history may also be reviewed to find out any other underlying condition that could be causing infections to the hair follicles. The doctor may perform dermoscopy of the scalp, which is a microscopic examination of scalp skin. Since it is difficult to confirm Scalp Folliculitis only on the basis of examination, in some cases, a sample of infected skin and hair is taken to perform swab test. This helps to identify the microorganism responsible for causing infection of hair follicle. In very rare cases, skin may be scraped off to send the sample for biopsy testing. This helps to rule out the possibility of other diseases of scalp and also confirms the diagnosis of Scalp Folliculitis.

What is the Treatment for Scalp Folliculitis?

The treatment for Scalp Folliculitis depends upon the severity of condition. Since Scalp Folliculitis is mainly caused due to microbial infection, medications to cure the infection become necessary. Other treatments such as surgery or laser hair removal may be needed in some cases.

Oral medications to treat infection

Oral medications are prescribed very rarely and are reserved only for severe cases of Folliculitis where the infection is spread in the deeper region of hair follicle.

Topical antimicrobial agents to treat infections

Topical antibacterial or antifungals in the form of lotions, creams, sprays or shampoos are prescribed to control the infections. The common antimicrobial agents include tetracycline, fusidic acid gel, erythromycin solution. Staphylococcus is the most common causative organism, anti-staphylococcal agents such as mupiricin or retapamulin ointment; topical clindamycin solution/lotion may be used.

Medication to treat inflammation

 Topical steroids and antihistamines are prescribed to reduce itching and inflammation.

How can you prevent Folliculitis?

Folliculitis can be prevented by following these tips

  • Avoid wearing tight caps, hats, scarfs, or other materials to avoid friction on the scalp
  • While shaving your scalp hair make sure not to shave too closely
  • While using public swimming pools, take a thorough shampoo wash once out from pool
  • Avoid pulling your hair into tight ponytails or braids
  • Wash your hair regularly with a mild shampoo
  • Avoid excessive use of hair styling products
  • Avoid sharing hygiene items such as comb, hair brushes, towels, etc.
  • Clean hair brushes and comb thoroughly after using

How to use home remedy to treat inflamed hair follicles?

Since Scalp Folliculitis is a result of bacterial infection, you can treat the inflamed hair follicles using some simple herbal anti-bacterial at home. However, if the infection is not being controlled it is best to visit doctor.

Herbs with antibacterial action 

Herbs such as aloe vera, neem, and garlic are known for their antibacterial properties. Pulp of fresh aloe vera, neem oil and Tulsi extract can be obtained easily and applied directly on the scalp to reduce itching, inflammation and infection in Scalp Folliculitis.

Herbal oils to treat inflammation

Herbal oils such as tea tree, coconut oil, castor oil are used for their antiseptic, anti-inflammatory and anti-oxidant actions. Tea tree oil shows good antimicrobial action can help to reduce bacterial and fungal infection in Scalp Folliculitis. Massage with warm coconut oil can help to sooth the irritation on scalp.

 Hot compresses

Hot compresses using warm cloth can help to reduce pain and discomfort. A cloth dipped in salt or vinegar solution can have beneficial effect in reducing itching and cleaning off the pus from pustules.

Types of Folliculitis

The classification of Folliculitis is very complex and has also been a topic of controversy. However, for better understanding experts have classified Folliculitis into three categories as infectious Folliculitis, non-infectious Folliculitis and peri-folliculitis.

Infectious or non-infectious Folliculitis can be either superficial or deep.

Infectious Folliculitis

Infectious Folliculitis can be caused by microorganisms such as bacteria, fungi or virus.

Bacterial Folliculitis

Bacterial Folliculitis is commonly caused by Staphylococcus aureus, streptococcus, proteus, pseudomonas or coliform bacilli. Factors such as inadequate use of topical corticosteroids, over exposure to oils or other chemical substances, or an ‘erosive pustular dermatosis’ can increase the chances of bacterial infection.

Superficial bacterial Folliculitis

Superficial infection affects the follicular ostium. It usually appears as a small white-yellow pustules located in follicular orifices surrounded by erythema.

Deep bacterial Folliculitis

Deep Folliculitis lasts for several days may leave a deep scar behind. These usually present as boils (furuncles) and a cluster of boils (carbuncles).These occur when hair follicles become deeply infected with staph bacteria.  

Fungal Folliculitis

Fungal Folliculitis also known as Dermatophytic Folliculitis  can be caused by dermatophytes, saprophytes such as Pityrosporum and Candida species. Based on the type of fungi the manifestation of the scalp lesions varies. For instance, Microsporous ringworm causes large round or polycyclic plaques whereas Trichophytic ringworm presents as multiple small alopecic areas. Kerion Celsi is a type of inflammatory tinea infection of the scalp caused by dermatophytes and is accompanied by severe inflammatory reaction.

Non-infectious Type of Folliculitis

Non-infectious Folliculitis is seen in adults who have compromised immunity or autoimmune in nature. Non-infection Folliculitis may also be caused due to mechanical and chemical traumas.

  • Folliculitis decalvans: This falls under this category. It causes abscesses inside the hair follicles that eventually results in scarring alopecia. It causes inflammation of the hair follicles which makes the follicles purulent accompanied by redness and swelling.
  • Folliculitis sclerotisans nuchae (keloidal Folliculitis): This is a scarring form of chronic Folliculitis that presents as follicular papules and pustules that eventually result in keloid-like lesion.
  • Tufted hair Folliculitis: This presents as a ‘tuft’ of hair made up of 5 to 20 hairs. Although it is classified as non-infectious Folliculitis it appears to be caused by aureus in immunocompromised people.
  • Erosive pustular dermatitis: This appears as pustular dermatosis with erosions and crusts covering the scalp. It is mainly caused due to secondary infection from aureus, or rarely S. epidermidis, Pseudomonas aeruginosa.
  • Acneiform eruptions: Acneiform eruptions are caused after an exposure to chlorinated compounds found in industry, usually in electrical conductors. This condition therefore falls under the category of occupation diseases.
  • Lichen planopilaris: This is seen commonly in women in the age group of 30 to 60 years. It causes follicular papules or erythematous plaques. Rarely, it produces patches of scarring alopecia on the scalp.

PeriFolliculitis

PeriFolliculitis   capitis abscendens et suffodiens is the most common disease under this category. It is caused by infection due to gram negative bacteria and seen more commonly among black men. The scalp lesion present as firm nodules that rapidly develop and discharge purulent material leading to hair loss. The inflammation progresses to dermis and can extend down into the subcutaneous fat, causing necrosis and scarring.