Acne and Folliculitis on the Scalp

Small red bumps, pustules, or "pimples at the roots" on the scalp are not always classic acne. Scalp folliculitis is a condition characterized by inflammation around the hair follicle and can be caused by various infectious or inflammatory factors.

Common causes include bacterial folliculitis, Malassezia-associated folliculitis, sweat-occlusion, harsh hair products, mechanical friction, and some inflammatory scalp diseases. While comedones are important in acne vulgaris, similar papules and pustules centered on the hair follicle are more typical in folliculitis.

Malassezia is part of the normal skin flora; it may play a role in some cases of scalp folliculitis. This does not mean that every case of scalp folliculitis is fungal. Heavy oil-based products, occlusive styling products, and excessive sweating can worsen lesions in some individuals.

Superficial folliculitis often does not cause permanent hair loss. However, in folliculitis decalvans and other forms of scarring alopecia, pustules, crusting, tufting, and permanent hair loss may develop. Signs such as hair loss, thick crusts, pain, or multiple hair strands emerging from the same follicular opening are important indicators of scarring.

Tinea capitis, especially in children, can mimic folliculitis with scaling, brittle hair, inflammation, and hair loss. Diagnosis may involve trichoscopy, bacterial culture, fungal examination, or biopsy as needed.

Treatment varies depending on the cause. Bacterial cases require an appropriate antibacterial approach, Malassezia-related cases require antifungal treatment, and inflammatory or scarring diseases require different treatments. It is not correct to treat every scalp folliculitis with a single shampoo or with long-term antibiotic treatment.