Here is a step-by-step algorithm for managing recurrent folliculitis (furunculosis):
1. Initial Evaluation
- History & Examination: Take a detailed medical history (including personal and family history of skin infections) and perform a thorough physical examination.
- Microbiological Testing: Obtain culture swabs from the lesions, and potentially from family members or close contacts, to identify the causative pathogen (often Staphylococcus aureus) and its antimicrobial resistance pattern.
- Consider PVL-positive S. aureus (MSSA/MRSA) in patients with multiple or recurrent boils/abscesses.
2. Initial Treatment for Acute Lesions
- Incision and Drainage (I&D): For solitary or fluctuant boils, simple I&D is often sufficient.
- Systemic Antibiotic Therapy:
- Consider systemic antibiotics if the infection is severe, rapidly progressing, involves multiple sites, or the patient has systemic illness, comorbidities, or immunosuppression.
- Use clinical judgment when choosing antibiotics, as S. aureus (including MRSA) may exhibit resistance to multiple agents.
- Outpatient: Oral clindamycin, trimethoprim-sulfamethoxazole, tetracyclines (doxycycline or minocycline), or linezolid. For β-hemolytic streptococci plus MRSA coverage, consider clindamycin or a combination of trimethoprim-sulfamethoxazole with a β-lactam (e.g., amoxicillin).
- Hospitalized Patients: For complicated infections, consider IV vancomycin, linezolid, daptomycin, telavancin, or clindamycin. Nonpurulent cellulitis may warrant the addition of a β-lactam (e.g., cefazolin).
- Duration: 7–14 days, tailored to the patient’s clinical response.
3. Prevention of Recurrent Episodes
- Personal Hygiene:
- Regular handwashing with soap or alcohol-based gel, particularly after touching infected skin.
- Keep wounds covered with clean, dry bandages.
- Avoid sharing personal items (e.g., razors, towels) that have contacted infected skin.
- Regular cleaning of frequently touched surfaces (counters, doorknobs) using appropriate commercial cleaners.
- Skin Barrier Maintenance: Use emollients regularly to maintain skin moisture and reduce the risk of skin barrier breakdown.
4. Decolonization for Recurrent Infections
- Consider decolonization if the patient has recurrent infections despite wound care and hygiene measures, or if there is transmission among household members.
- Topical Decolonization Regimen:
- Mupirocin ointment applied in the nostrils twice daily for 5–10 days then once weekly.
- Daily body wash with 2% chlorhexidine skin wash for 5–14 days, then revert to once or twice a week. Cleanse the perineal area and underarms thoroughly, shampoo hair daily, and let the wash sit for 30 seconds before rinsing. Avoid vigorous scrubbing and keep the product away from the eyes and ear canals.
- Optional: Dilute bleach baths (Add 60mL (¼ cup) of household bleach (6% hypochlorite) to a deep bath. Soak in the water up to your neck for 15 minutes daily, avoiding contact with the face and eyes. Be cautious, as concentrated bleach is corrosive.
- For resistant cases: Topical gentian violet 0.3% solution to the nostrils for 2–3 weeks.
- Oral Antimicrobial Therapy: Not routinely recommended for decolonization unless infection persists. If necessary, a combination of an oral agent with rifampicin (if the strain is susceptible) may be used.
- Consider testing and treating family members if they are carriers of the same strain of S. aureus.
5. Management of Systemic Complications
- Systemic Antibiotics: If there are systemic signs of infection (e.g., fever, systemic illness), systemic antibiotics are mandatory. Adjust antibiotics based on culture results.
- Hospitalization & Isolation: For MRSA infections, hospitalize the patient if severe and isolate them to prevent transmission.
6. Long-Term Management
- Nutritional Status: Ensure any nutritional deficiencies or comorbidities are addressed.
- Regular Skin Monitoring: Regular follow-up to monitor for new lesions or complications. Swab cultures can be repeated periodically to adjust antimicrobial therapy.
- Family Screening: Screen and decolonize household members if they are found to be carriers.
7. Conclusion
- Furunculosis, especially recurrent or complicated cases, requires a multifaceted approach including hygiene, decolonization, and appropriate systemic or topical therapy. Future studies may explore the role of probiotics or alternative approaches to antimicrobial therapy.
References
- Recurrent furunculosis – challenges and management: a review[link]
- Recurrent Boils (furunculosis): Guidelines for management and Staphylococcal decolonisation (MRSA and MSSA)[link]
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