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Meta-Analysis
. 2021 Feb 26;2(2):CD013099.
doi: 10.1002/14651858.CD013099.pub2.

Interventions for bacterial folliculitis and boils (furuncles and carbuncles)

Huang-Shen Lin  1 , Pei-Tzu Lin  2 , Yu-Shiun Tsai  3 , Shu-Hui Wang  4 , Ching-Chi Chi  5   6
Affiliations
Meta-Analysis

Interventions for bacterial folliculitis and boils (furuncles and carbuncles)

Huang-Shen Lin et al. Cochrane Database Syst Rev. .

Abstract

Background: Bacterial folliculitis and boils are globally prevalent bacterial infections involving inflammation of the hair follicle and the perifollicular tissue. Some folliculitis may resolve spontaneously, but others may progress to boils without treatment. Boils, also known as furuncles, involve adjacent tissue and may progress to cellulitis or lymphadenitis. A systematic review of the best evidence on the available treatments was needed.

Objectives: To assess the effects of interventions (such as topical antibiotics, topical antiseptic agents, systemic antibiotics, phototherapy, and incision and drainage) for people with bacterial folliculitis and boils.

Search methods: We searched the following databases up to June 2020: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We also searched five trials registers up to June 2020. We checked the reference lists of included studies and relevant reviews for further relevant trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that assessed systemic antibiotics; topical antibiotics; topical antiseptics, such as topical benzoyl peroxide; phototherapy; and surgical interventions in participants with bacterial folliculitis or boils. Eligible comparators were active intervention, placebo, or no treatment.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. Our primary outcomes were 'clinical cure' and 'severe adverse events leading to withdrawal of treatment'; secondary outcomes were 'quality of life', 'recurrence of folliculitis or boil following completion of treatment', and 'minor adverse events not leading to withdrawal of treatment'. We used GRADE to assess the certainty of the evidence.

Main results: We included 18 RCTs (1300 participants). The studies included more males (332) than females (221), although not all studies reported these data. Seventeen trials were conducted in hospitals, and one was conducted in clinics. The participants included both children and adults (0 to 99 years). The studies did not describe severity in detail; of the 232 participants with folliculitis, 36% were chronic. At least 61% of participants had furuncles or boils, of which at least 47% were incised. Duration of oral and topical treatments ranged from 3 days to 6 weeks, with duration of follow-up ranging from 3 days to 6 months. The study sites included Asia, Europe, and America. Only three trials reported funding, with two funded by industry. Ten studies were at high risk of 'performance bias', five at high risk of 'reporting bias', and three at high risk of 'detection bias'. We did not identify any RCTs comparing topical antibiotics against topical antiseptics, topical antibiotics against systemic antibiotics, or phototherapy against sham light. Eleven trials compared different oral antibiotics. We are uncertain as to whether cefadroxil compared to flucloxacillin (17/21 versus 18/20, risk ratio (RR) 0.90, 95% confidence interval (CI) 0.70 to 1.16; 41 participants; 1 study; 10 days of treatment) or azithromycin compared to cefaclor (8/15 versus 10/16, RR 1.01, 95% CI 0.72 to 1.40; 31 participants; 2 studies; 7 days of treatment) differed in clinical cure (both very low-certainty evidence). There may be little to no difference in clinical cure rate between cefdinir and cefalexin after 17 to 24 days (25/32 versus 32/42, RR 1.00, 95% CI 0.73 to 1.38; 74 participants; 1 study; low-certainty evidence), and there probably is little to no difference in clinical cure rate between cefditoren pivoxil and cefaclor after 7 days (24/46 versus 21/47, RR 1.17, 95% CI 0.77 to 1.78; 93 participants; 1 study; moderate-certainty evidence). For risk of severe adverse events leading to treatment withdrawal, there may be little to no difference between cefdinir versus cefalexin after 17 to 24 days (1/191 versus 1/200, RR 1.05, 95% CI 0.07 to 16.62; 391 participants; 1 study; low-certainty evidence). There may be an increased risk with cefadroxil compared with flucloxacillin after 10 days (6/327 versus 2/324, RR 2.97, 95% CI 0.60 to 14.62; 651 participants; 1 study; low-certainty evidence) and cefditoren pivoxil compared with cefaclor after 7 days (2/77 versus 0/73, RR 4.74, 95% CI 0.23 to 97.17; 150 participants; 1 study; low-certainty evidence). However, for these three comparisons the 95% CI is very wide and includes the possibility of both increased and reduced risk of events. We are uncertain whether azithromycin affects the risk of severe adverse events leading to withdrawal of treatment compared to cefaclor (274 participants; 2 studies; very low-certainty evidence) as no events occurred in either group after seven days. For risk of minor adverse events, there is probably little to no difference between the following comparisons: cefadroxil versus flucloxacillin after 10 days (91/327 versus 116/324, RR 0.78, 95% CI 0.62 to 0.98; 651 participants; 1 study; moderate-certainty evidence) or cefditoren pivoxil versus cefaclor after 7 days (8/77 versus 5/73, RR 1.52, 95% CI 0.52 to 4.42; 150 participants; 1 study; moderate-certainty evidence). We are uncertain of the effect of azithromycin versus cefaclor after seven days due to very low-certainty evidence (7/148 versus 4/126, RR 1.26, 95% CI 0.38 to 4.17; 274 participants; 2 studies). The study comparing cefdinir versus cefalexin did not report data for total minor adverse events, but both groups experienced diarrhoea, nausea, and vaginal mycosis during 17 to 24 days of treatment. Additional adverse events reported in the other included studies were vomiting, rashes, and gastrointestinal symptoms such as stomach ache, with some events leading to study withdrawal. Three included studies assessed recurrence following completion of treatment, none of which evaluated our key comparisons, and no studies assessed quality of life.

Authors' conclusions: We found no RCTs regarding the efficacy and safety of topical antibiotics versus antiseptics, topical versus systemic antibiotics, or phototherapy versus sham light for treating bacterial folliculitis or boils. Comparative trials have not identified important differences in efficacy or safety outcomes between different oral antibiotics for treating bacterial folliculitis or boils. Most of the included studies assessed participants with skin and soft tissue infection which included many disease types, whilst others focused specifically on folliculitis or boils. Antibiotic sensitivity data for causative organisms were often not reported. Future trials should incorporate culture and sensitivity information and consider comparing topical antibiotic with antiseptic, and topical versus systemic antibiotics or phototherapy.

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Conflict of interest statement

Huang‐Shen Lin: none known. Pei‐Tzu Lin: none known. Yu‐Shiun Tsai: none known. Shu‐Hui Wang: none known. Ching‐Chi Chi: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Ofloxacin gel versus norfloxacin gel, Outcome 1: Clinical cure
2.1
2.1. Analysis
Comparison 2: Sisomicin ointment versus gentamicin ointment, Outcome 1: Clinical cure
2.2
2.2. Analysis
Comparison 2: Sisomicin ointment versus gentamicin ointment, Outcome 2: Minor adverse events not leading to withdrawal of treatment
3.1
3.1. Analysis
Comparison 3: Dieda Xiaoyan Gao ointment versus ichthammol ointment, Outcome 1: Clinical cure
4.1
4.1. Analysis
Comparison 4: Erythromycin versus flucloxacillin, Outcome 1: Minor adverse events not leading to withdrawal of treatment
5.1
5.1. Analysis
Comparison 5: Cefadroxil versus flucloxacillin, Outcome 1: Clinical cure
5.2
5.2. Analysis
Comparison 5: Cefadroxil versus flucloxacillin, Outcome 2: Severe adverse events leading to withdrawal of treatment
5.3
5.3. Analysis
Comparison 5: Cefadroxil versus flucloxacillin, Outcome 3: Minor adverse events not leading to withdrawal of treatment
6.1
6.1. Analysis
Comparison 6: Cefdinir versus cefalexin, Outcome 1: Clinical cure
6.2
6.2. Analysis
Comparison 6: Cefdinir versus cefalexin, Outcome 2: Severe adverse events leading to withdrawal of treatment
7.1
7.1. Analysis
Comparison 7: Azithromycin versus cefaclor, Outcome 1: Clinical cure subgroup
7.2
7.2. Analysis
Comparison 7: Azithromycin versus cefaclor, Outcome 2: Clinical cure
7.3
7.3. Analysis
Comparison 7: Azithromycin versus cefaclor, Outcome 3: Minor adverse events not leading to withdrawal of treatment
8.1
8.1. Analysis
Comparison 8: Ciprofloxacin versus pentoxifylline plus ciprofloxacin, Outcome 1: Clinical cure
8.2
8.2. Analysis
Comparison 8: Ciprofloxacin versus pentoxifylline plus ciprofloxacin, Outcome 2: Recurrence of folliculitis or boil following completion of treatment
9.1
9.1. Analysis
Comparison 9: Fleroxacin versus amoxicillin/clavulanate, Outcome 1: Clinical cure
9.2
9.2. Analysis
Comparison 9: Fleroxacin versus amoxicillin/clavulanate, Outcome 2: Severe adverse events leading to withdrawal of treatment
9.3
9.3. Analysis
Comparison 9: Fleroxacin versus amoxicillin/clavulanate, Outcome 3: Minor adverse events not leading to withdrawal of treatment
10.1
10.1. Analysis
Comparison 10: Cefditoren pivoxil versus cefaclor, Outcome 1: Clinical cure
10.2
10.2. Analysis
Comparison 10: Cefditoren pivoxil versus cefaclor, Outcome 2: Severe adverse events leading to withdrawal of treatment
10.3
10.3. Analysis
Comparison 10: Cefditoren pivoxil versus cefaclor, Outcome 3: Minor adverse events not leading to withdrawal of treatment
11.1
11.1. Analysis
Comparison 11: S‐1108 versus cefaclor , Outcome 1: Clinical cure
11.2
11.2. Analysis
Comparison 11: S‐1108 versus cefaclor , Outcome 2: Minor adverse events not leading to withdrawal of treatment
12.1
12.1. Analysis
Comparison 12: SY 5555 versus cefaclor, Outcome 1: Clinical cure
12.2
12.2. Analysis
Comparison 12: SY 5555 versus cefaclor, Outcome 2: Severe adverse events leading to withdrawal of treatment
12.3
12.3. Analysis
Comparison 12: SY 5555 versus cefaclor, Outcome 3: Minor adverse events not leading to withdrawal of treatment
13.1
13.1. Analysis
Comparison 13: Grepafloxacin versus ofloxacin, Outcome 1: Clinical cure
13.2
13.2. Analysis
Comparison 13: Grepafloxacin versus ofloxacin, Outcome 2: Minor adverse events not leading to withdrawal of treatment
14.1
14.1. Analysis
Comparison 14: Co‐trimoxazole plus 8‐MOP and sunlight versus co‐trimoxazole plus placebo and sunlight, Outcome 1: Lesion‐free rate
15.1
15.1. Analysis
Comparison 15: Fire cupping plus penicillin versus penicillin, Outcome 1: Clinical cure
16.1
16.1. Analysis
Comparison 16: Wound packing versus no wound packing following incision and drainage , Outcome 1: Pain score (48 h post‐incision and drainage)
16.2
16.2. Analysis
Comparison 16: Wound packing versus no wound packing following incision and drainage , Outcome 2: Recurrence rate (1 month)
17.1
17.1. Analysis
Comparison 17: Primary STSG versus delay STSG, Outcome 1: Survival of STSG
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References to ongoing studies

CTRI/2015/01/005361 {published data only}
    1. CTRI/2015/01/005361. Comparative efficacy, safety and tolerability of fixed dose combination of Cephalexin extended release (375 mg) and Clavulanate Potassium (125 mg) tablets with Cephalexin extended release (375 mg) tablets in the treatment of uncomplicated skin and soft tissue infection. ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=9459 (first received 6 January 2015).
CTRI/2018/03/012411 {published data only}
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References to other published versions of this review

Lin 2018
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