Pseudofolliculitis of the Beard

Background

Pseudofolliculitis barbae (PFB) or shaving bumps is a foreign body inflammatory reaction involving papules and pustules. It primarily affects curly haired males who shave.^[1] Pseudofolliculitis barbae can also affect some white men and hirsute black women. Pseudofolliculitis pubis is a similar condition occurring after pubic hair is shaved.

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Pathophysiology

Two mechanisms are involved in the pathogenesis of pseudofolliculitis barbae: (1) extrafollicular penetration occurs when a curly hair reenters the skin, and (2) transfollicular penetration occurs when the sharp tip of a growing hair pierces the follicle wall.

Black men who shave are predisposed to this condition because of their tightly curved hair. The sharp pointed hair from a recent shave briefly surfaces from the skin and reenters a short distance away. Several methods of close shaving result in a hair cut below the surface. These methods include pulling the skin taut while shaving, shaving against the grain, plucking hairs with tweezers, removing hairs with electrolysis, and using double- or triple-bladed razors. The close shave results in a sharp tip below the skin surface, which is then more likely to pierce the follicular wall, causing pseudofolliculitis barbae with transfollicular penetration.^{[2, 3]}

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Etiology

African Americans are genetically predisposed to pseudofolliculitis barbae because of the curvature of their hair follicles. Improper shaving techniques and the desire for a clean-shaven appearance can result in ingrown hairs via extrafollicular or transfollicular penetration.

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Epidemiology

US frequency

About 10-80% of adult black men have pseudofolliculitis barbae, particularly those who shave closely on a regular basis.^[4] It is a significant problem in black men in the military where regulations require a clean-shaven face.^[5]

Race

Pseudofolliculitis barbae is found mostly in black men.

Sex

Men with facial hair comprise most patients, although hirsute women can also develop pseudofolliculitis barbae. Both sexes can develop pseudofolliculitis pubis. Common sites in black women and those of ethnic backgrounds characterized by darker skin include the pubic and axillary areas because these are more frequent sites of hair removal in this population.

Age

Pseudofolliculitis barbae affects men with facial hair (postpuberty).

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Prognosis

Although usually not regarded as a serious medical problem, pseudofolliculitis barbae can cause cosmetic disfigurement. The papules can lead to scarring, postinflammatory hyperpigmentation, secondary infection, and keloid formation. No cure exists, but effective treatment is available. If the patient is able to grow a beard, the problem usually disappears (except for any residual scarring).

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Patient Education

Instruct the patient to stop shaving for 3-4 weeks. This gives adequate time for the hair follicles to grow to a length where ingrown hairs will spring free.

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History

Patients report a painful acneiform eruption that occurs after shaving. The patient's shaving history, including the method and the frequency, may reveal an improper shaving technique. The method for preparation of the beard, the use of medications or depilatories, and the use of hair-releasing procedures should be discussed with the patient.

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Physical Examination

The primary lesion is a flesh-colored or erythematous papule with a hair shaft in its center. If the hair shaft is gently lifted up, the free end of the hair comes out of the papule. These inflammatory papules are seen in shaved areas adjacent to the follicular ostia, as shown in the image below.

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Pseudofolliculitis barbae on the neck of a black man.

Pustules and abscess formation can occur from secondary infection.

Postinflammatory hyperpigmentation, scarring, and keloid formation may occur in chronic or improperly treated cases.

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Complications

Although usually not regarded as a serious medical problem, pseudofolliculitis barbae may cause cosmetic disfigurement. The papules may lead to scarring, postinflammatory hyperpigmentation, secondary infection, and keloid formation.

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Laboratory Studies

A clinical diagnosis can usually be made.

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Procedures

A case of sarcoid infiltrating lesions of pseudofolliculitis barbae has been documented. Biopsy may be performed if sarcoidosis is suspected.

See Medical Care and Deterrence/Prevention for a discussion of shaving and hair-release techniques.

Dermoscopy has been used to demonstrate the pathophysiology and improve compliance.^{[7, 8]}

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Histologic Findings

The penetrating hair causes invagination of the epidermis with inflammation and intraepidermal abscesses. With penetration of the dermis, the epidermis grows down to try to ensheathe the hair, and severe inflammation, abscess formation, and a foreign-body giant cell reaction occur at the tip of the hair.

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Medical Care

Chemical depilatories

Chemical depilatories work by breaking the disulfide bonds in hair, which results in the hair being broken off bluntly at the follicular opening.^[9]

Barium sulfide powder depilatories of about 2% strength can be made into a paste with water and applied to the beard area. This paste is removed after 3-5 minutes.

Calcium thioglycolate preparations come as powder, lotions, creams, and pastes. The mercaptan odor is often masked with fragrance. In rare cases, this fragrance can cause an allergic reaction. Calcium thioglycolate preparations take longer to work and are left on 10-15 minutes; chemical burns result if left on too long.

Chemical depilatories should not be used every day because they cause skin irritation. Every second or third day is an acceptable regimen. Irritation can be countered by using hydrocortisone cream. A lower pH or concentration, or a different brand, may also prove less irritating. Several products are available; therefore, trying a different product is encouraged if one depilatory proves to be unacceptable.

Topical medications

Topically applied tretinoin (Retin-A) has shown promise for some patients. When used nightly, it alleviates hyperkeratosis. It may remove the thin covering of epidermis that the hair becomes embedded in upon emerging from the follicle.^{[10, 11]}

Topical combination cream (tretinoin 0.05%, fluocinolone acetonide 0.01%, and hydroquinone 4%) (Triluma) has been shown to provide some benefit by targeting the hyperkeratosis (tretinoin), inflammation (fluocinolone), and postinflammatory hyperpigmentation (hydroquinone).^[12]

Mild topical corticosteroid creams reduce inflammation of papular lesions.^[10]

Topical eflornithine HCL 13.9% cream (Vaniqa) has been used for excessive facial hair and in patients with pseudofolliculitis barbae. It is also used as a combination with laser therapy for hirsute women and pseudofolliculitis barbae patients. It decreases the rate of hair growth. In addition, the treated hair may become finer and lighter.^[13]

Antibiotics

For severe cases of pseudofolliculitis barbae with pustules and abscess formation, topical and oral antibiotics may be indicated.^{[14, 15]}

Topical antibiotics may successfully reduce skin bacteria and treat secondary infection. These topicals include erythromycin, clindamycin, and combination clindamycin/benzoyl peroxide (Benzaclin, Duac) and erythromycin/benzoyl peroxide (Benzamycin) agents. Applying one of these agents once or twice per day is effective. Benzoyl peroxide applied topically once a day is also effective in reducing bacterial populations. It should be used sparingly and may be irritating to sensitive skin. It is a good first-line topical agent for persons with oily skin. Benzamycin is a combination of erythromycin and benzoyl peroxide. A once daily application has the benefits of both agents.

If pustules or abscess formation is evident, an oral antibiotic is indicated. Tetracycline is a common choice for a systemic antibiotic. Similar to a standard acne regimen, a dose of 500 mg twice a day used initially for 1-3 months is often effective.

Special considerations

Pseudofolliculitis barbae is of particular concern in persons in the military. Enforcement of a clean-shaven face in those with this condition can cause scarring, hyperpigmentation, secondary infection, and keloid formation. The lack of understanding of this disease has created tension and hostility between soldiers and their chain of command. Proper education on shaving methods and treatment of pseudofolliculitis barbae, including judicious breaks from shaving (no shaving profiles), is essential.^{[16, 17, 18]}

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Surgical Care

Newer hair removal lasers may have a role in the treatment of pseudofolliculitis barbae. The problem with most laser and high-intensity light source hair removal modalities is that the natural skin pigment may be damaged by the laser because melanin in the hair shaft is the target chromophore. Devices being studied at this time may avoid this depigmenting complication. Diode laser treatments have been proven safe and effective in patients with skin phototypes I-IV.^{[19, 20, 21, 22]}

The use of long-pulsed Nd:Yag laser in the treatment of pseudofolliculitis barbae demonstrated a decrease in papule formation, miniaturization, and reduction of hair counts in skin types IV, V and VI.^[23] Most subjects had a return of normal hair growth after 6 months; however, 2 of 10 individuals had areas of permanent hair loss after 12-month follow-up. Adverse effects of long-standing hypopigmentation in this study were isolated, signifying that this particular laser is an encouraging modality of therapy.^[24]

Reportedly, excellent results can be obtained with the use of an 800-nm diode laser technique with low power and high pulse duration (5-15 J/cm², 2 Hz, 100–400 ms), especially in darker-skinned individuals.^[25]

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Diet

No dietary therapies for pseudofolliculitis barbae have proven effective, and no dietary triggers of the condition have been identified.

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Prevention

Hair-releasing procedures and shaving should be performed after a shower to hydrate and soften both the skin and the hair. Subsequent shaving results in a duller, rounded tip to the hair, which is less likely to reenter the skin.

Wash the beard with a face cloth, a wet sponge, or a soft-bristled toothbrush with a mild soap for several minutes using a circular motion. This technique helps to dislodge stubborn tips.

Using needles or toothpicks to dislodge stubborn tips is controversial. It usually is not recommended because overly aggressive digging with sharp objects can cause further damage to the skin.

Patients with pseudofolliculitis barbae may use razors if single-edged, foil-guarded, safety razors are used.^[26] Double- or triple-bladed razors shave too closely and should not be used. Commercially available foil-guarded razors have about 30% of the blade covered by foil, which prevents the blade from shaving the hair too closely.

Electric razors have acceptable results if used properly. The recommended technique with a 3-headed rotary electric razor is to keep the heads slightly off the surface of the skin and to shave in a slow, circular motion. Do not press the electric razor close to the skin or pull the skin taut because this results in too close of a shave. Some electric razors have "dial in" settings for the closeness of the shave. These may be effective if kept off of the closest settings.

Electric clippers are effective for resistant cases of pseudofolliculitis barbae. With clippers, 1- to 2-mm stubble can be left on the face. The tendency to shave too closely is reduced with this method, making it more effective. The appearance of stubble may be cosmetically unacceptable for some patients.

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Long-Term Monitoring

Outpatient evaluation and patient education is effective. With proper techniques, transfollicular and extrafollicular penetration can be minimized.

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Medication Summary

Hydrocortisone cream is effective in reducing inflammation. Topical and oral antibiotics are used when secondary infection is evident. Tretinoin has shown promise in early pseudofolliculitis barbae. Chemical depilatories are preferential to shaving for some patients.

Chemical depilatories are effective alternatives to shaving for some patients. They work by breaking disulfide bonds in hair follicles. Barium sulfide is a fast-acting depilatory powder that is mixed with water to form a paste. Similarly, calcium thioglycolate is an effective depilatory that is left on for 10-15 minutes for effective hair removal.

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Tetracycline

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Clinical Context:  Tetracycline is used orally to treat secondary infection. It treats gram-positive and gram-negative organisms, as well as mycoplasmal, chlamydial, and rickettsial infections. It inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits.

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Erythromycin topical (AkneMycin, Ery)

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Clinical Context:  Topical erythromycin 2% inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is used for staphylococcal and streptococcal infections.

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Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Topical preparations reduce bacterial populations and secondary infection.

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Tretinoin topical (Retin-A, Atralin, Tretin-X, Refissa)

• Dosing, Interactions, etc.

Clinical Context:  Topical tretinoin inhibits microcomedo formation and eliminates existing lesions. It makes keratinocytes in sebaceous follicles less adherent and easier to remove. Applied topically, it reduces outbreaks of mild pseudofolliculitis barbae. It is available as 0.025%, 0.05%, and 0.1% creams and as 0.01% and 0.025% gels.

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Class Summary

These agents decrease the cohesiveness of abnormal hyperproliferative keratinocytes, and they may reduce the potential for malignant degeneration. They modulate keratinocyte differentiation. They have been shown to reduce the risk of skin cancer formation in patients who have undergone renal transplantation.

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Hydrocortisone 1% topical (Cortaid, Westcort, Colocort, Caldecort, Cortizone-10)

• Dosing, Interactions, etc.

Clinical Context:  Hydrocortisone 1% topical cream is an adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. It has mineralocorticoid and glucocorticoid effects, resulting in anti-inflammatory activity. It is effective when used topically on a short-term basis.

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Eflornithine HCL (Vaniqa)

• Dosing, Interactions, etc.

Clinical Context:  Oral eflornithine inhibits ornithine decarboxylase, which affects the rate of hair growth (anagen phase). It slows hair growth, and some reports indicate miniaturization of hair growth to areas treated. It may take 4-8 weeks for improvement; however, the condition may return to pretreatment levels 8 weeks after discontinuance of therapy.

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Class Summary

These agents are used to reduce inflammation and irritation. These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.

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