Is My Rash Psoriasis or Folliculitis? How to Identify the Difference

Psoriasis and Folliculitis are two common skin conditions that give rise to patches of red, irritated skin, that can appear deceptively similar at the first glance. But if you take a closer look, these two conditions have unique characteristics that will help you easily identify which one it is.

Correct identification is very important as they have different causes and treatments. We bring you all the knowledge you need to make this demarcation accurately, and help you improve your skin health.

What Is Psoriasis?

Psoriasis vulgaris characterized by thick, red, and scaly patches on the skin

Psoriasis is a long-term inflammatory skin condition that give rise to well demarcated red patches of skin covered in silvery scales, usually seen on the outside of knees or elbows, on the scalp and on the lower back.^[1] It affects 1-3% of people globally, with different rates among various ethnic groups and regions.^[2] These psoriatic patches are often dry, flaky, itchy and can be painful. This typical type of psoriasis is called ‘plaque psoriasis’ which is seen in 85% to 90% of patients with psoriasis.^[1] However, there are other less common types which might differ from the typical appearance.

• Guttate psoriasis/ eruptive psoriasis: This type is commonly seen in children, usually following an episode of sore throat. The lesions in this type appear as red scaly rain drop shaped patches on trunk and back.
• Pustular psoriasis: In this type you can have red rimmed small lesions filled with pus, without any bacteria or other organisms causing an infection.
• Erythrodermic psoriasis: Special characteristic of this type is extensive involvement of the body, often causing more than 90% of the skin to become red, itchy, painful and exfoliated.

There are instances where other body areas are involved, such as nails, tongue (oral psoriasis), inside of elbows and knees (flexural psoriasis), scalp (Sebo psoriasis), joints and eyes. About 30% of people suffering from psoriasis get psoriatic arthritis, where the joints become painfully inflamed with sausage shaped swelling of fingers and toes (dactylitis).^[1]

Psoriasis is caused by a mix of genetic factors and environmental triggers such as UV exposure, certain medications, smoking, alcohol, infections, and stress that act as triggering factors. It does not spread from person to person. However, because of the chronic nature of the disease, you will have to be on regular medication and continuous management to keep the symptomps from appearing.

What Is Folliculitis?

Folliculitis lesion on the nose caused by a bacterial infection, displaying redness and pus-filled inflammation

Simply put, folliculitis is the infection of the hair follicle. It is fairly common, temporary and may even heals on its own.^[3] Folliculitis appear as red bumps or pustules on hair-covered areas on the skin. These tiny lesions can be painful and itchy. It can be caused by bacterial infections, fungal species, viruses, or mites like Demodex folliculorum. Sometimes, it can also occur without an infection, due to factors like irritation.^[3] While healthy individuals need not be overly concerned about folliculitis, people with weak immune systems like HIV patients can experience severe effects. While day today activities like shaving, tight clothes, hot water baths and direct injury can trigger folliculitis, with the right treatment it completely disappears without lasting long.

Psoriasis or Folliculitis. How to tell them apart?

Psoriasis vulgaris (left) on the foot vs. Folliculitis (right) on the groin – showing the characteristic thick, red, scaly plaques with silvery scales in psoriasis compared to the small red bumps/pustules around hair follicles

Table 1: Common symptoms of Psoriasis and Folliculitis

Table 2: Cause comparison

Location of the lesions on your skin gives a pretty good idea as to whet condition it is. While psoriasis can occur anywhere on the body, especially outside of knees or elbows, scalp and back, folliculitis is generally seen in areas that are hair bearing. Appearance can be used to demarcate the two as well, as explained above. But on rare occasion some types of psoriasis like pustular psoriasis can mimic folliculitis as both cause pus filled small bumps. Furthermore, the chronic nature of psoriasis with symptomatic episodes called flare-ups, and the temporary nature of folliculitis with complete recovery with treatment is a failsafe way to tell these apart. Other associated symptoms each condition show will further confirm the conclusion. For example, psoriasis can be associated with joint pains, in which case the condition is known as psoriatic arthritis.

Table 3: Symptoms at a glance

Causes and risk factors

Psoriasis has an immune mediated origin, and a genetic predisposition, meaning if somebody related to you have psoriasis, there is a bigger chance you also might have it. Activated ‘T cells’, a type of immune cells in your body causes the keratinocytes, (keratin laden cells in the outermost layer of skin) to divide rapidly. This excessive proliferation is the reason for the red scaly plaques seen in psoriasis. Furthermore, these cells cannot secrete lipids like normal skin cells, which is the cause for the dry and flaky skin typically seen in psoriasis. Often there is some kind of triggering factor responsible for the appearance of the symptoms. Common triggers include physical injuries (mechanical, chemical or radiation), certain medications (chloroquine, lithium, beta-blockers, steroids, and NSAID), seasonal changes (improves in summer and worsens in winter), and lifestyle habits (alcohol, smoking, obesity, psychological stress).

In contrast, folliculitis is usually caused by some organism infecting the hair follicles. Bacterial is the commonly seen organism, the most common culprit being Staphylococcus aureus. Shaving, using hot tubs, wearing tight clothes and overall poor hygiene can increase the risk of folliculitis.^[4]

Treatment options

Even though it is a skin condition, managing psoriasis will need a team of medical professionals in different specialties. It needs medical interventions depending on the severity, which is widely determined using Psoriasis Area Severity Index (PASI). Mild to moderate cases can be treated with topical therapy, including coal tar, dithranol, corticosteroids, vitamin D analog, and retinoids.^[5],[6],[7] Emollients and moisturizers help retain hydration and keep the skin healthy. When these simple methods fail, your dermatologist may prescribe you stronger oral or injected medicine like Cyclosporine, Methotrexate and biologic agents (eg: Infliximab).^[1] Phototherapy, where the affected skin is exposed to ultraviolet light, is another effective way of treatment.

To prevent flare ups, avoid triggers, get adequate sunlight exposure, and maintain healthy body weight. There are no special dietary requirements, so try to stick to a healthy diet. Also, getting screened for diabetes, high blood pressure and dyslipidemia can be helpful in managing psoriasis.

On the other hand, folliculitis might not need treatment at all. Especially simple folliculitis is known to heal on its own with a varying duration depending on what causes the infection.

• Folliculitis with Staphylococcus aureus bacteria- few days^[1]
• Folliculitis with gram negative bacteria- 7 to 10 days^[1]

You can promote natural healing with warm compresses. However, if it doesn’t go away on its own, treatment with topical or oral medication is needed, again depending on the causative organism.

• Bacterial folliculitis- topical antibiotics (mupirocin and clindamycin), oral antibiotics (cephalexin and dicloxacillin)^[8]
• Folliculitis with gram negative bacteria- oral antibiotics (ampicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin)^[9]
• Fungal folliculitis- topical/ oral antifungal agents (Itraconazole and fluconazole)
• Viral folliculitis- oral acyclovir, valacyclovir, and famciclovir.

Table 4: Summary of treatment options for Psoriasis and Folliculitis

Could It Be Something Other Than Psoriasis or Folliculitis?

Unfortunately, your condition can be something other than both psoriasis and folliculitis as well because there are many different skin conditions that cause similar appearing lesions.

Fungal infections like ringworms can mimic flexural psoriasis, especially when occurring in the groin area. Typical psoriasis can be hard to differentiate form conditions like seborrheic dermatitis, pityriasis rosacea and secondary syphilis as well.

Folliculitis can be confused with acne, scabies, pseudo folliculitis barbae and papulopustular rosacea, as all of these conditions give rise to small pus-filled bumps. Therefore, careful and close look into the lesions is very important to correctly identify the condition.

When to See a Doctor

If psoriasis or folliculitis symptoms persist, worsen, or show signs of infection (like redness, swelling, or pus), seek medical advice without delay. A dermatologist can diagnose these conditions through close inspection or biopsies. In psoriasis, on successive removal of scales pinpoint bleeding points are seen. Your healthcare provider will use simple examination techniques like this to come to a correct decision. They will recommend appropriate treatments, helping you get rid of the symptoms faster.

Conclusion

Psoriasis and folliculitis are similar looking skin conditions that are very different in origin and the way of management. Psoriasis is the more bothersome of the two, which almost invariably require medical attention. If you have any symptoms described above, take a careful and close look at the lesions and try to identify the condition, and go for relevant treatment. If the symptoms last long, or if it becomes irritating, consult your dermatologist at once to get quick relief of the symptoms. Be alert, and adhere to simple preventive methods to maintain healthy and vibrant skin.