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Dermatology (Expert Forum)
Folliculitis - Dermatitis - Rhinitis - Antibiotics?
Answered by
Alan Rockoff, MD - dermatology, Child Skin Problems
The Rockoff Dermatology Center
Brookline - MA
This forum is for questions regarding Dermatology issues, such as: skin rashes, acne, birthmarks, skin infections, rosacea, and general skin care.
Folliculitis - Dermatitis - Rhinitis - Antibiotics?
by martina_it, May 30, 2004 12:00AM
I am 36 and have suffered from what doctors here in Italy diagnosed as atopic dermatitis since 1995. From 1995 to 1998 I was told to continuously use mainly cortisone creams and also occasionally antibiotic creams (Bactroban) but with no lasting relief. I was also given antibacterial cleansers (Uria peroxide) , but that caused big red “splotches” that the doctors called eczema which I had not had until then. A recent “patch test” showed that I am allergic to perfumes and dust.
In 1998 I was in Texas and a dermatologist told me that I also had a folliculitis infection (since I have chronic rhinitis, the infection could come from the nose…when I told an Italian doctor, he just smiled…) which was “under the skin” so it had no white head. In his opinion that was why the antibiotic creams were not successful in solving the problem: they didn’t reach the infection. Instead he said that the combination of the creams and my scratching only spread the infection creating a vicious circle. He prescribed an oral low dose of doxycycline for 50 days after which the problem cleared up to a level of only a few spots in 5 years treatable with very little hydrocortisone. In this year during which I was also pregnant my dermatitis flared up again. Now that my son is 6 months old the harsh phase of the dermatitis seems to have passed, but my arms, legs and hands continue to have problems that begin with small isolated red pimples which I scratch and then the entire area gets inflamed. Sometimes the pimples have white heads of “classical folliculitis” and sometimes they don’t. The Italian dermatologists told me it is dermatitis without really looking at my skin and ,as in the past, prescribed also “strong” cortisone (ie. Flubasone). I used Bactroban by myself and my skin reacts positively but not enough to stop my scratching and eliminate the infection. I don’t want to use too much cortisone if it is mainly a folliculitis …my skin, especially my hands, is quiet ruined from too much use already. Another dermatologist proposed Tacrolymus (less side effects), but how can I use that if I have an infection?
My personal physician knows that the Texas dermatologist’s treatment worked well for me and made sense, but offered to prescribe me a higher dose of doxycycline for 8 days (a lower dose does not exist) and told me that in Italy this is not commonly used for the skin. My worry is that the low-dose longer treatment was for a reason and that the short-term high-dose will not have the same results. Am I wrong? Could you please give me your general opinion? What treatment makes sense to you? What about the implications of my nose (rhinitis = constant dripping/sneezing? A blood test showed that I had a very high level of eosinofili which was confirmed by a nasal swab test). Is it so difficult recognize the difference between dermatitis and “under the skin” folliculitis?
In 1998 I was in Texas and a dermatologist told me that I also had a folliculitis infection (since I have chronic rhinitis, the infection could come from the nose…when I told an Italian doctor, he just smiled…) which was “under the skin” so it had no white head. In his opinion that was why the antibiotic creams were not successful in solving the problem: they didn’t reach the infection. Instead he said that the combination of the creams and my scratching only spread the infection creating a vicious circle. He prescribed an oral low dose of doxycycline for 50 days after which the problem cleared up to a level of only a few spots in 5 years treatable with very little hydrocortisone. In this year during which I was also pregnant my dermatitis flared up again. Now that my son is 6 months old the harsh phase of the dermatitis seems to have passed, but my arms, legs and hands continue to have problems that begin with small isolated red pimples which I scratch and then the entire area gets inflamed. Sometimes the pimples have white heads of “classical folliculitis” and sometimes they don’t. The Italian dermatologists told me it is dermatitis without really looking at my skin and ,as in the past, prescribed also “strong” cortisone (ie. Flubasone). I used Bactroban by myself and my skin reacts positively but not enough to stop my scratching and eliminate the infection. I don’t want to use too much cortisone if it is mainly a folliculitis …my skin, especially my hands, is quiet ruined from too much use already. Another dermatologist proposed Tacrolymus (less side effects), but how can I use that if I have an infection?
My personal physician knows that the Texas dermatologist’s treatment worked well for me and made sense, but offered to prescribe me a higher dose of doxycycline for 8 days (a lower dose does not exist) and told me that in Italy this is not commonly used for the skin. My worry is that the low-dose longer treatment was for a reason and that the short-term high-dose will not have the same results. Am I wrong? Could you please give me your general opinion? What treatment makes sense to you? What about the implications of my nose (rhinitis = constant dripping/sneezing? A blood test showed that I had a very high level of eosinofili which was confirmed by a nasal swab test). Is it so difficult recognize the difference between dermatitis and “under the skin” folliculitis?
Doctor's Answer
by Alan Rockoff, MD, May 31, 2004 12:00AM
, May 31, 2004 12:00AM
I am not familiar with "under the skin folliculitis", having neither seen nor heard of it. Besides, folliculitis doesn't itch. Moreover, the bacteria in folliculitis are staphylococci, which generally don't respond to doxyxycline.
Some doctors treat atopic dermatitis with antibiotics, oral and topical, at least intermittently, thinking that bacteria play at least a secondary role. It's conceivable that that's why doxyxycline worked. There's no advantage I can think of in terms of efficacy to a low dose.
As to tacrolimus, that does not cause or promote infection, so your concerns are unnecessary. Cortisone creams also theoretically weaken immunity, but in practice this is no issue at all.
In sum, I think you indeed have atopic dermatitis, perhaps with bacterial contribution. Since tacrolimus has never been used, I would try it. Depending on the response, I would consider a regimen of bacterial suppression using an antiseptic cleanser to wash with, an antibacterial like Bactroban applied nightly to the nostrils to suppress staph colonization, and a short course of an oral antibiotic effective against staph, perhaps one of the penicillins. Aggressive anti-itch measures (such as creams containing camphor and menthol) should also be used.
If tacrolimus doesn't help enough, regular use of suitable steroids are best.
Please keep in mind that eczema is a lifelong, intermittent condition, which can be suppressed, but always returns sooner or later.
Best.
Dr. Rockoff
Some doctors treat atopic dermatitis with antibiotics, oral and topical, at least intermittently, thinking that bacteria play at least a secondary role. It's conceivable that that's why doxyxycline worked. There's no advantage I can think of in terms of efficacy to a low dose.
As to tacrolimus, that does not cause or promote infection, so your concerns are unnecessary. Cortisone creams also theoretically weaken immunity, but in practice this is no issue at all.
In sum, I think you indeed have atopic dermatitis, perhaps with bacterial contribution. Since tacrolimus has never been used, I would try it. Depending on the response, I would consider a regimen of bacterial suppression using an antiseptic cleanser to wash with, an antibacterial like Bactroban applied nightly to the nostrils to suppress staph colonization, and a short course of an oral antibiotic effective against staph, perhaps one of the penicillins. Aggressive anti-itch measures (such as creams containing camphor and menthol) should also be used.
If tacrolimus doesn't help enough, regular use of suitable steroids are best.
Please keep in mind that eczema is a lifelong, intermittent condition, which can be suppressed, but always returns sooner or later.
Best.
Dr. Rockoff
