Folliculitis, Furuncles, and Carbuncles - Bacterial Infections: Pyodermas

FOLLICULITIS, FURUNCLES, AND CARBUNCLES

Folliculitis is an infection of bacterial or fungal origin that arises within the hair follicles. Lesions may be superficial or deep. Sin-gle or multiple papules or pustules appear close to the hair folli-cles. Folliculitis commonly affects the beard area of men who shave and women’s legs. Other areas include the axillae, trunk, and buttocks.

Pseudofolliculitis barbae (ie, shaving bumps) are an inflam-matory reaction that occurs predominately on the faces of African American and other curly-haired men as a result of shaving. The sharp ingrowing hairs have a curved root that grows at a more acute angle and pierces the skin, provoking an irritative reaction. The only entirely effective treatment is to avoid shaving. Other treatments include using special lotions or antibiotics or using a hand brush to dislodge the hairs mechanically. If the patient mustremove facial hair, a depilatory cream or electric razor may be more appropriate than a straight razor.

A furuncle (ie, boil) is an acute inflammation arising deep in one or more hair follicles and spreading into the surrounding der-mis. It is a deeper form of folliculitis. Furunculosis refers to mul-tiple or recurrent lesions. Furuncles may occur anywhere on the body but are more prevalent in areas subjected to irritation, pres-sure, friction, and excessive perspiration, such as the back of the neck, the axillae, and the buttocks.

A furuncle may start as a small, red, raised, painful pimple. Frequently, the infection progresses and involves the skin and subcutaneous fatty tissue, causing tenderness, pain, and sur-rounding cellulitis. The area of redness and induration represents an effort of the body to keep the infection localized. The bacte-ria (usually staphylococci) produce necrosis of the invaded tissue. The characteristic pointing of a boil follows in a few days. When this occurs, the center becomes yellow or black, and the boil is said to have “come to a head.”

A carbuncle is an abscess of the skin and subcutaneous tissue that represents an extension of a furuncle that has invaded several follicles and is large and deep seated. It is usually caused by a staphylococcal infection. Carbuncles appear most commonly in areas where the skin is thick and inelastic. The back of the neck and the buttocks are common sites. In carbuncles, the extensive inflammation frequently prevents a complete walling off of the in-fection; absorption may occur, resulting in high fever, pain, leuko-cytosis, and even extension of the infection to the bloodstream.

Furuncles and carbuncles are more likely to occur in patients with underlying systemic diseases, such as diabetes or hemato-logic malignancies, and in those receiving immunosuppressive therapy for other diseases. Both are more prevalent in hot cli-mates, especially on skin beneath occlusive clothing.

Medical Management

In treating staphylococcal infections, it is important not to rup-ture or destroy the protective wall of induration that localizes the infection. The boil or pimple should never be squeezed.

Follicular disorders, including folliculitis, furuncles, and car-buncles, are usually caused by staphylococci; although if the immune system is impaired, the causative organisms may be gram-negative bacilli. Systemic antibiotic therapy, selected by sen-sitivity study, is generally indicated. Oral cloxacillin, dicloxacillin, and flucloxacillin are first-line medications. Cephalosporins and erythromycin are also effective. Bed rest is advised for patients who have boils on the perineum or in the anal region, and a course of systemic antibiotic therapy is indicated to prevent the spread of the infection.

When the pus has localized and is fluctuant, a small incision with a scalpel can speed resolution by relieving the tension and ensuring direct evacuation of the pus and slough. The patient is instructed to keep the draining lesion covered with a dressing.

Nursing Management

Intravenous fluids, fever reduction, and other supportive treat-ments are indicated for patients who are very ill or suffering with toxicity. Warm, moist compresses increase vascularization and hasten resolution of the furuncle or carbuncle. The surrounding skin may be cleaned gently with antibacterial soap, and an anti-bacterial ointment may be applied. Soiled dressings are handled according to standard precautions. Nursing personnel should carefully follow isolation precautions to avoid becoming carriers of staphylococci. Disposable gloves are worn when caring for these patients.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care.To prevent and control staphylo-coccal skin infections such as boils and carbuncles, the staphy-lococcal pathogen must be eliminated from the skin and environment. Efforts must be made to increase the patient’s re-sistance and provide a hygienic environment. If lesions are ac-tively draining, the mattress and pillow should be covered with plastic material and wiped off with disinfectant daily; the bed linens, towels, and clothing should be laundered after each use; and the patient should use an antibacterial soap and shampoo for an indefinite period, often for several months.

Recurrent infection is prevented with the use of prescribed an-tibiotic therapy (eg, a daily dose of oral clindamycin to be taken continuously for about 3 months). The patient must take the full dose for the time prescribed. The purulent exudate (ie, pus) is a source of reinfection or transmission of infection to caregivers. When the patient has a history of recurrent infections, a carrier state may exist, which should be investigated and treated with an antibacterial cream such as mupirocin.