appear, especially in immunocompromised patients. These lesions typically resolve spontaneously. Topical therapy with erythromycin, clindamycin, mupirocin, or benzoyl peroxide can be administered to accelerate the healing process.25 Staphylococci will occasionally invade the deeper portion of the follicle, causing swelling and erythema with or without a pustule at the skin surface. These lesions are painful and may scar. This inflammation of the entire follicle or the deeper portion of the hair follicle (isthmus and below) is called deep folliculitis. Oral antibiotics are usually used in the treatment and include first-generation cephalosporins, penicillinase-resistant penicillins, macrolides, and fluoroquinolones. Gram-negative folliculitis usually involves the face and affects patients with a history of long-term antibiotic therapy for acne. Pathogens include Klebsiella, Enterobacter, and Proteus species. It can be treated as severe acne with isotretinoin (Accutane), but use of isotretinoin is associated with major side effects, including birth defects.26 “Hot tub” folliculitis is caused by Pseudomonas aeruginosa contamination of under-treated water in a hot tub or whirlpool. Multiple pustular or papular perifollicular lesions appear on the trunk and sometimes extremities within six to 72 hours after exposure (Figure 6), and mild fever and malaise may occur. Lesions in the immunocompetent patient typically resolve spontaneously within a period of seven to 10 days.25 Treatment is directed at prevention by appropriately cleaning the whirlpool or hot tub and maintaining appropriate chlorine levels (bromine and copper solutions are less common alternatives) in the water. Furuncles and Carbuncles Furuncles and carbuncles occur as a follicular infection progresses deeper and extends out from the follicle (Table 1). Commonly known as an abscess or boil, a furuncle is a tender, erythematous, firm or fluctuant mass of walled-off purulent material, arising from the hair follicle. These lesions may occur anywhere on the body, but have a predilection for areas exposed to friction. Furuncles rarely appear before puberty. The pathogen is usually S. aureus. Typically, the furuncle will develop into a fluctuant mass and eventually open to the skin surface, allowing the purulent contents to drain, either spontaneously or following incision of the furuncle. Carbuncles are an aggregate of infected hair follicles that form broad, swollen, erythematous, deep, and painful masses that usually open and drain through multiple tracts. Constitutional symptoms, including fever and malaise, are commonly associated with these lesions but are rarely found with furuncles. With both of these lesions, gentle incision and drainage is indicated when lesions “point” (fluctuant or boggy with a thin shiny appearance of the overlying skin); caution should be taken to not incise deeper than the pseudo capsule that has been built at the site of infection. Loculations should be broken with a hemostat. The wound may be packed (usually with iodoform gauze) to encourage further drainage. In severe cases, parenteral antibiotics such as cloxacillin (Tegopen), or a first-generation cephalosporin such as cefazolin (Ancef), are required.27 The physician should be aware of the potential for gas-containing abscesses or necrotizing fasciitis, which require immediate surgical debridement. The majority of bacterial skin infections are caused by the gram-positive bacteria Staphylococcus and Streptococcus species. Antibiotics are used empirically with consideration for resistance patterns. Current antibiotic recommendations include penicillinase-resistant penicillins, first-generation cephalosporins, azithromycin, clarithromycin, amoxicillin-clavulanic acid, or a second-generation fluoroquinolone in the skeletally mature patient. Gram-negative coverage with a second-, third-, or fourth-generation cephalosporin is usually indicated in children under three years and in patients with diabetes or who are immunocompromised. DANIEL L. STULBERG, M.D., is director of dermatology curriculum at the Utah Valley Family Practice Residency in Provo, Utah. Dr. Stulberg received his medical