Folliculitis Following Burn Injury

Disclosure: Presented at the Asia Pacific Burns Congress incorporating the Australian and New Zealand Burns Association Annual Scientific Meeting in Brisbane, Australia, September 8–12, 2003 Introduction Patients who have sustained burns to any hair-bearing area of their bodies are susceptible to the often painful infectious complication of folliculitis. Folliculitis is defined simply as “inflammation of the hair follicles.”[1] The infection is secondary to trauma from burn injury, which causes damage to the hair follicle and allows pathogens to gain access via small breaks in the skin. Folliculitis can occur in superficial to deep partial-thickness burns. It may occur either on the site of the burn or on a previously healed or healing donor site. Sauer describes folliculitis as a “pyogenic infection…usually caused by coagulase-positive staphylococci.”[2] Pathogens that have been found in the wound swabs of our patients with folliculitis are coagulase-positive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter calcoaceticus sub. anitratus, and coagulase-negative Staphylococcus.

The organism found in all swabs taken at our facility is S. aureus. Because skin is the largest immune organ of the body, it is not unusual for patients who sustain burns to become immunosuppressed.[3] Blauveld indicates that immunosuppressed patients are prone to infections caused by opportunistic organisms.[4] Burn folliculitis is nondiscriminatory as to age and gender. Caucasian, Asiatic, and dark-skinned people have all been affected. Patients who suffer from flame burns, chemical burns, flash burns, and electrical burns can all develop folliculitis. Following burn injury, folliculitis may occur on the body and on the head. These two types of folliculitis are different, but there are also similarities as described in this article (Table 1). Burn Folliculitis on the Body Folliculitis on the body begins as red spots that develop into pustules. The pustules break open and develop crusts around the edge of the wound bed. The wounds vary in size but are generally small, superficial, and fast spreading. The infection can recur. The incidence of this type of folliculitis is difficult to measure. We performed a retrospective search of 430 burn-injury patient medical records, which provided no information, as folliculitis is rarely documented in these records.

Occasionally, a record stated there was breakdown on either the donor sites or on the grafted or healing wounds; however, what caused these breakdowns was not recorded. Burn Folliculitis on the Head and Scalp Folliculitis on the head and scalp begins as small pimples or pustules around one or more hair follicles. When the pustules burst, a crust forms that resembles impetigo. Unlike impetigo, there is no blister. The wounds are open with yellow-brown crusts formed around the margin. Within this margin is a thick clear to yellow mucoid fluid that covers the wound. The wound bed is red, appears inflamed, and bleeds easily. Patients state that these wounds are slightly itchy and very painful, especially when touched. Unless treated correctly, folliculitis can spread rapidly. When it heals, alopecia usually results. It is a chronic condition and may recur many times. Until recently, the treatment for folliculitis following burn injury in our facility consisted of soaking the crusts in a vegetable oil for a minimum of one hour. The crusts, softened by the oil, were then removed using forceps. The affected area was rinsed with a weak solution of five-percent chlorhexidine to remove the loosened remaining debris and to clean the wounds. A topical antimicrobial, such povidone-iodine, silver sulfadiazine and chlorhexidine, mupirocin, or triclosan, to which the microbes were sensitive was applied to the freshly cleaned wounds. This treatment regimen would sometimes take in excess of two hours to carry out and would need to be performed daily. Recently, a bath oil containing paraffin and five-percent colloidal oatmeal (Dermaveen Shower and Bath OilTM, Dermatech Laboratories, Australia) was used in our facility in place of the vegetable oil regimen to treat folliculitis from burn injury. The following two case reports illustrate the successful use of this shower and bath oil.

Case Study

Patient 1. A 24-year-old male patient sustained 30-percent total body surface area (TBSA) burns in a helicopter accident. The burns to his head and scalp were noted to be deep partial- to full-thickness burns. Six weeks post burn, he developed folliculitis. The folliculitis was first noticed on his scalp and his ears. Swabs showed the presence of MRSA and P. aeruginosa. While in the burn unit, the burn staff performed the vegetable oil treatment regimen on the patient daily. Due to the discomfort caused to the patient by the procedure, the clinicians administered the maximum prescribed dose of morphine and anti-anxiety medication to the patient prior to the treatment. The patient would then self-administer nitrous oxide during the procedure. Povidone-iodine, silver sulfadiazine and chlorhexidine, mupirocin, and triclosan were each used for 1 to 2 weeks before changing to one of the other preparations. In addition to the vegetable oil treatment, the patient was taken to the operating room twice to have his scalp shaved and cleaned to reduce the number of microbes present in his hair. The folliculitis was still present when he was discharged after 10 weeks in the burn unit. Community nurses continued to carry out the vegetable oil treatment regimen daily on an outpatient basis. The patient would allow them to treat part of the area until he could no longer tolerate the pain. The burns specialist at the outpatient clinic used different combinations of antiseptic solutions and antimicrobials weekly without success. Six weeks post discharge, at his weekly outpatient appointment, the burns specialist suggested that the patient come into the hospital for a day to have his head shaved and cleaned again under anesthetic, but the patient refused. The folliculitis was spreading and was now present over much of his scalp, the sides of his face, and his ears (Figures 1A and B).

Once, the clinicians applied a topical local anesthetic to the patient’s scalp to reduce the pain prior to cleaning and dressing the wounds with no effect. Clinicians also applied boric acid, olive oil, and zinc cream with clioquinol once but the patient refused to use it again, as he claimed it was too messy. The patient continued using the povidone-iodine solution. After seven weeks of outpatient treatment using the traditional folliculitis treatment method with no success, the burns specialist suggested using a shower and bath oil containing paraffin and five-percent colloidal oatmeal (Dermaveen Shower and Bath Oil™, Dermatech Laboratories, Australia) on the patient’s scalp instead of the vegetable oil. Fifteen minutes after the application, clinicians removed the crusted areas more easily and with less pain than during previous procedures. Povidone-iodine was used as the antimicrobial solution. When the patient returned to the clinic three weeks later, there were small unhealed areas but the inflamed appearance of infection was replaced by more healthy appearing skin and the patient’s scalp was pain-free (Figure 2). At this point, the use of the communnity nurses was discontinued, and the patient’s mother continued his wound treatment. She applied the shower and bath oil and povidone-iodine solution daily. Four weeks after initiating the wound treatment using the shower and bath oil, the folliculitis resolved and the patient’s scalp healed. The folliculitis recurred from time to time over the next 18 months, but would clear within three days by using the shower and bath oil and povidone-iodine solution as soon the spots were noticed. The patient now has alopecia on many areas of his scalp.

Patient 2. A 48-year-old woman sustained 10-percent TBSA flame burns. Although two areas on her scalp had deep partial burns, grafting was not carried out. It was expected that these wounds would heal spontaneously as they were only 1.5 to 3cm in diameter. Burns to her neck just below the hairline had been grafted. When folliculitis was noticed on her scalp and ear, a swab was taken and the wound care procedure was carried out using the shower and bath oil for cleansing, aqueous chlorhexidine to rinse, and povidone-iodine as the antimicrobial. Although asked to remove the crusts, the community nurses who performed the patient’s daily dressings felt it was wrong to remove the crusts. As a result, a week later the scalp wounds were crusty and had increased in size (Figure 3). The community nurses were educated about the importance of removing the crusts from the wounds. The results of the patient’s swabs were misplaced so further swabs had to be taken. The following week, other areas of folliculitis appeared. One of the original wounds was healing but her wounds still appeared inflamed. The topical treatment was changed from povidone-iodine to mupirocin to which the S. aureus had shown a sensitivity. A week later her scalp no longer appeared inflamed and was almost healed (Figure 4). Even with the problems that arose, this patient only suffered with the folliculitis for 2 to 3 weeks. When her scalp healed, alopecia was present.

Two and a half years post injury, the patient continues to have recurrences of this infection, but she self-treats them with the shower and bath oil, aqueous chlorhexidine, and povidone-iodine as soon as the lesions appear. The lesions heal quickly using this regimen. Incidence of Burn Folliculitis A chart search was done to find the incidence of folliculitis following burn injury. Four-hundred and thirty charts of acute burns patients admitted to the Royal Brisbane Hospital burns unit over a two and a half year period from 1999 to 2001 were searched. Of those 430 cases, there were 21 cases of folliculitis. This was approximately five percent of the acute burns cases admitted to the ward. Of the 143 patients who had burns to the head and survived, there were 21 (15%) who developed folliculitis. The depth of the burns to the head of those 21 patients who developed folliculitis was recorded as deep partial to full thickness. In all, there were 23 patients who had these deeper burns to the scalp and head who had survived. Therefore, 91 percent of the patients who suffered deep burns to their heads developed folliculitis. Discussion Folliculitis of the body and of the scalp should be treated using the same wound care regimen.

The time to heal using the shower and bath oil is reduced from months to weeks or days compared to the vegetable oil treatment. Soaking the scalp in vegetable oil for an hour was replaced by soaking in the shower and bath oil for 15 to 30 minutes, thus reducing the time the regimen takes. The shower and bath oil softens the crusts and removes the mucoid covering on the wounds, something the weak chlorhexidine solution did not do. Once this covering is removed, the antimicrobial can achieve better penetration into the wounds and thus destroy the pathogens, which are found in and under the crusts. Unless these crusts are removed, the infection will continue to spread. The topical antimicrobials that have been used with success at our facility are mupirocin, chloromycetin, and povodine iodine. The use of systemic antibiotics has not assisted in clearing this infection. The risk of developing scalp folliculitis is greater in patients with deep partial burns.

This supports the finding of Barret, et al., who found that second-degree burns are a risk factor in the development of folliculitis.[1,5] If occlusive dressings are to be used post healing, such as for scar management, it is our experience the infection will quickly recur. It has been theorized that the folliculitis recurs because the pathogen causing the infection remains in a space around the hair follicle over which scar tissue has grown. A fresh outbreak occurs as an oil gland, hair follicle, or the pocket of infection breaking through the scar tissue makes an opening to the surface. Conclusion Burn folliculitis is painful and unsightly whether on the body or the head. The wound care procedure to treat folliculitis is still time consuming but the new regimen has decreased the time that it takes to resolve the infection. By resolving the infection quicker, there is less pain and fewer hair follicles are lost. This may reduce the amount of alopecia patients experience.