Vulvar Folliculitis

Vulvar folliculitis is inflammation or infection of vulval hair follicles, usually from Staphylococcus aureus after shaving, waxing, friction or occlusion.

• Pseudomonas aeruginosa can cause folliculitis after hot tub or swimming pool exposure.
• Most cases are mild and self-limited.
• Recurrence suggests carriage of S. aureus, diabetes or hidradenitis suppurativa.

Small, tender or itchy red papules and pustules, each centred on a hair, on the labia majora and mons pubis.

• Usually multiple, without fever.
• Differential diagnosis: furuncle, herpes genitalis, candidal folliculitis, molluscum contagiosum, hidradenitis suppurativa, pseudofolliculitis barbae, scabies, genital warts.
• Complications: furuncle, abscess, cellulitis, post-inflammatory pigmentation and scarring.

Diagnosis is clinical.

• Swab pustule for Gram stain and culture when lesions are numerous, persistent or recurrent.
• Random blood glucose and HIV test for recurrent cases.
• Vesicle swab for herpes simplex NAAT if lesions are painful, grouped and ulcerated.
• Biopsy for atypical lesions.

Treat with a topical antibiotic and hygiene measures, adding an oral antibiotic for deep or extensive lesions.

• Supportive: stop shaving or waxing until healed (use trimming, not shaving); warm compresses for 10 to 15 minutes, 3 times daily; wash with chlorhexidine 4 percent solution or antibacterial soap; cotton underwear; wash towels and underwear at 60 degrees Celsius; avoid squeezing lesions.
• Pharmacological: mupirocin 2 percent ointment applied thinly 3 times daily for 5 to 10 days. For extensive or deep lesions, flucloxacillin 500 mg oral 6-hourly for 5 to 7 days (child 12.5 to 25 mg/kg 6-hourly, maximum 500 mg per dose). Penicillin allergy: clindamycin 300 mg oral 8-hourly for 5 to 7 days (child 3 to 6 mg/kg 6-hourly, maximum 450 mg per dose). Candidal folliculitis: clotrimazole 1 percent cream twice daily for 2 weeks. Recurrent staphylococcal disease: mupirocin 2 percent intranasal twice daily for 5 days with chlorhexidine 4 percent body wash daily for 5 to 7 days.
• Procedures: none; incise and drain only if a fluctuant abscess forms.
• Special groups: in pregnancy avoid topical corticosteroids on infected skin and avoid doxycycline; flucloxacillin and clindamycin are acceptable. In diabetes check and control glucose.
• Red flags: fever, spreading erythema, large painful nodules, systemic illness.
• Follow-up: review at 1 to 2 weeks; refer for dermatology review if recurrent beyond 3 episodes in a year.