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Pseudofolliculitis Barbae
Maurice Duggins, MD
image BASICS
DESCRIPTION
  • Foreign-body inflammatory reaction from an ingrown hair resulting in the appearance of papules and pustules. This is found mainly in the bearded area (barbae) but may occur in other hairy locations such as the scalp, axilla, or pubic areas where shaving is done (1).
  • A mechanical problem: extrafollicular and transfollicular hair penetration
  • System(s) affected: skin/exocrine
  • Synonym(s): chronic sycosis barbae; pili incarnate; folliculitis barbae traumatica; razor bumps; shaving bumps; tinea barbae; pseudofolliculitis barbae (PFB)
EPIDEMIOLOGY
  • Predominant age: postpubertal, middle age (14 to 25 years) (2)
  • Predominant sex: male > female (can be seen in females of all races who wax/shave)
Incidence
  • Adult male African Americans: unknown
  • Adult male whites: unknown
Prevalence
  • Widespread in Fitzpatrick skin types IV-VI (darker complexions) who shave
  • 45-83% of African American soldiers who shave (1)
ETIOLOGY AND PATHOPHYSIOLOGY
  • Transfollicular escape of the low-cut hair shaft as it tries to exit the skin is accompanied by inflammation and often an intraepidermal abscess.
  • As the hair enters the dermis, more severe inflammation occurs, with downgrowth of the epidermis in an attempt to sheath the hair.
  • A foreign-body reaction forms at the tip of the invading hair, followed by abscess formation.
  • Shaving too close
  • Plucking/tweezing or wax depilation of hair may cause abnormal hair growth in injured follicles.
Genetics
  • People with curly hair have an asymmetric accumulation of acidic keratin hHa8 on hair shaft.
  • Single-nucleotide polymorphism (disruption Ala12Thr substitution) affects keratin of hair follicle.
RISK FACTORS
  • Curly hair
  • Shaving too close or shaving with multiple razor strokes
  • Plucking/tweezing hairs
  • South Mediterranean/American, Middle Eastern, Asian, or African descent (skin types IV-VI)
GENERAL PREVENTION
  • Prior to shaving, rinse face with warm water to hydrate and soften hairs.
  • Use adjustable hair clippers that leave very low hair length above skin.
  • Shave with either a manual adjustable razor at coarsest setting (avoids close shaves), a single-edge blade razor (e.g., Bump Fighter), a foil-guarded razor (e.g., PFB razor), or electric triple “O-head” razor.
  • Empty razor of hair frequently.
  • Shave in the direction of hair growth. Do not overstretch skin when shaving.
  • Use a generous amount of the correct shaving cream/gel (e.g., Ef-Kay Shaving Gel, Edge Shaving Gel, Aveeno Therapeutic Shave Gel, Easy Shave Medicated Shaving Cream).
  • Daily shaving reduces papules/pruritus.
  • Regular use of depilatories
COMMONLY ASSOCIATED CONDITIONS
  • Keloidal folliculitis
  • Pseudofolliculitis nuchae
image DIAGNOSIS
PHYSICAL EXAM
  • Tender, exudative, erythematous follicular papules or pustules in beard area (less commonly in scalp, axilla, and pubic areas); range from 2 to 4 mm
  • Hyperpigmented “razor or shave bumps”
  • Alopecia
  • Lusterless, brittle hair
DIFFERENTIAL DIAGNOSIS
  • Bacterial folliculitis
  • Impetigo
  • Acne vulgaris
  • Tinea barbae
  • Sarcoidal papules
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Clinical diagnosis
  • Culture of pustules: usually sterile; may show coagulase-negative Staphylococcus epidermidis (normal skin flora)
  • Additional hormonal testing may be indicated in females with hirsutism and/or polycystic ovary syndrome: dehydroepiandrosterone sulfate, luteinizing hormone (LH)/follicle-stimulating hormone (FSH), and free and total testosterone (3)[C].
Test Interpretation
Follicular papules and pustules
image TREATMENT
  • Mild cases
    • Stop shaving or avoid close shaving for 30 days while keeping beard groomed and clean (1,2)[C].
    • Consider 5% benzoyl peroxide after shaving and application of 1% hydrocortisone cream at bedtime (or LactiCare HC lotion after shaving) (2)[C].
    • Tretinoin 0.025% cream; apply daily(1)[C]
  • Moderate cases
    • Chemical depilatories (barium sulfide; Magic Shave powder); first test on forearm for 48 hours (for irritation) (1,2,3)[B]
    • Consider eflornithine HCl cream (Vaniqa) to reduce hair growth and stiffness in combination with other therapies (1,4)[B].
  • Severe cases
    • Laser therapy: Longer wavelength laser (e.g., neodymium [Nd]:YAG) is safer for dark skin (5)[B].
    • Avoid shaving altogether; grow beard (1,2,3)[C].
GENERAL MEASURES
Acute treatment
  • Dislodge embedded hair with sterile needle/tweezers.
  • Discontinue shaving until red papules have resolved (minimum 3 to 4 weeks; longer if moderate or severe); can trim to length >0.5 cm during this time.
  • Massage beard area with washcloth, coarse sponge, or a soft brush several times daily.
  • Hydrocortisone 1-2.5% cream to relieve inflammation
  • Selenium sulfide if seborrhea is present and to help reduce pruritus
  • Systemic antibiotics if secondary infection is present
P.873

Pregnancy Considerations
Do not use tretinoin (Retin-A), tetracycline, or benzoyl peroxide.
MEDICATION
First Line
  • Topical or systemic antibiotic for secondary infection
    • Application of clindamycin (Cleocin T) solution BID or topical erythromycin
    • Low-dose erythromycin or tetracycline 250 to 500 mg PO BID for more severe inflammation
    • Benzoyl peroxide 5%-clindamycin 1% gel BID: Administer until papule/pustule resolves.
  • Mild cases: tretinoin 0.025% cream at bedtime; combination of the above therapies
  • Moderate disease/chemical depilatories
    • Disrupt cross-linking of disulfide bonds of hair to produce blunt (less sharp) hair tip.
    • Apply no more frequently than every 3rd day: 2% barium sulfide (Magic Shave) or calcium thioglycollate (Surgex); calcium hydroxide (Nair)
  • Contraindications
    • Clindamycin: hypersensitivity history; history of regional enteritis or ulcerative colitis; history of antibiotic-associated colitis
    • Erythromycin, tetracycline, tretinoin: hypersensitivity history
  • Precautions
    • Clindamycin: colitis, eye burning and irritation, skin dryness; pregnancy Category B
    • Erythromycin: Use cautiously in patients with impaired hepatic function; GI side effects, especially abdominal cramping; pregnancy Category B (erythromycin base formulation).
    • Chemical depilatories: Use cautiously; frequent use and prolonged application may lead to irritant contact dermatitis and chemical burns.
    • Tetracycline: Avoid in pregnancy.
    • Tretinoin: Severe skin irritation; avoid in pregnancy.
    • Benzoyl peroxide: skin irritation and dryness, allergic contact dermatitis
    • Hydrocortisone cream: local skin irritation, skin atrophy with prolonged use, lightening of skin color
  • Significant possible interactions
    • Erythromycin: increases theophylline and carbamazepine levels; decreases clearance of warfarin
    • Tetracycline: depresses plasma prothrombin activity
Second Line
Chemical peels with either glycolic acid or salicylic acid
ISSUES FOR REFERRAL
  • Worsening or poor response to the above therapies after 4 to 6 weeks should prompt dermatology consultation.
  • Occupational demands may also prompt earlier referral to dermatology for more aggressive therapy.
SURGERY/OTHER PROCEDURES
Laser treatment with long-pulsed Nd:YAG is helpful for severe cases.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • As needed
  • Educate patient on curative and preventive treatment.
DIET
  • No restrictions
  • No dietary studies available
PATIENT EDUCATION
  • https://medlineplus.com/
  • http://www.uptodate.com/home
PROGNOSIS
  • Good, with preventive methods
  • Prognosis is poor in the presence of progressive scarring and foreign-body granuloma formation.
REFERENCES
1. Bridgeman-Shah S. The medical and surgical therapy of pseudofolliculitis barbae. Dermatol Ther. 2004;17(2):158-163.
2. Perry PK, Cook-Bolden FE, Rahman Z, et al. Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends. J Am Acad Dermatol. 2002;46(2)(Suppl):S113-S119.
3. Quarles FN, Brody H, Johnson BA, et al. Pseudofolliculitis barbae. Dermatol Ther. 2007;20(3):133-136.
4. Xia Y, Cho S, Howard RS, et al. Topical eflornithine hydrochloride improves the effectiveness of standard laser hair removal for treating pseudofolliculitis barbae: a randomized, double-blinded, placebo-controlled trial. J Am Acad Dermatol. 2012;67(4):694-699.
5. Weaver SM III, Sagaral EC. Treatment of pseudofolliculitis barbae using the long-pulse Nd:YAG laser on skin types V and VI. Dermatol Surg. 2003;29(12):1187-1191.
Additional Reading
&NA;
  • Cook-Bolden FE, Barba A, Halder R, et al. Twicedaily application of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae. Cutis. 2004;73(6) (Suppl):18-24.
  • Daniel A, Gustafson CJ, Zupkosky PJ, et al. Shave frequency and regimen variation effects on the management of pseudofolliculitis barbae. J Drugs Dermatol. 2013;12(4):410-418.
  • Kindred C, Oresajo CO, Yatskayer M, et al. Comparative evaluation of men's depilatory composition versus razor in black men. Cutis. 2011;88(2):98-103.
  • Kundu RV, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominately in skin of color. Am Fam Physician. 2013;87(12):859-865.
See Also
&NA;
Folliculitis; Impetigo
Codes
&NA;
ICD10
  • L73.1 Pseudofolliculitis barbae
  • B35.0 Tinea barbae and tinea capitis
  • L73.8 Other specified follicular disorders
Clinical Pearls
&NA;
  • Electrolysis is not recommended as a treatment. It is expensive, painful, and often unsuccessful.
  • Combination of laser therapy with eflornithine is more effective than laser alone.
  • Use Bump Fighter razor from American Safety Razor Company (http://www.asrco.com/).
  • Men may prefer the convenience of the Bump Fighter razor over depilatory products.
  • The aversive smell of sulfur could be a problem with some depilatory products.
  • Have patient test for skin sensitivity with a small (coin-sized) amount of the depilatory on the bearded area or forearm.