Published on 16/03/2015 by admin
Filed under Dermatology
Last modified 16/03/2015
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Gary J. Brauner
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Pseudofolliculitis barbae (PFB) is a chronic inflammatory disease of hair-bearing areas induced by shaving or plucking of curved hairs, with resultant transepithelial or transfollicular penetration by the sharpened hair remnant and a foreign body reaction. It is characterized clinically by papules, papulopustules, focal or diffuse postinflammatory hyperpigmentation, growth grooves, and rarely hypertrophic or keloidal scarring.
Because this process is induced by shaving its cure is simple: by not shaving or plucking at all and allowing the hairs to grow to beyond 1 cm in length, the disease will spontaneously involute. If a clean-shaven appearance is preferred or deemed necessary by occupational or social demands, management involves three elements:
Extraction of the foreign body by lifting the embedded distal sharpened ends of hairs
Prevention of further embedding by proper shaving technique or permanent disruption of the follicle’s ability to produce new hair
Treatment of postinflammatory hyperpigmentation or hypertrophic scarring.
Embedded hairs should be lifted, not plucked, just prior to shaving. A safety razor set on its ‘gentlest’ setting, or a pre-adjusted razor such as the PFB Bumpfighter™, should be used, but with the opposite hand kept off the face to prevent skin stretching. Shaving is performed in the direction of hair growth, not against it, again to prevent too-close shaving and transfollicular penetration. A long pre-soak with a hot wet facecloth will allow hairs to swell and lift; a shaving cream that lathers and holds well will keep those hairs saturated and elevated. Shaving must be performed daily; by 2 to 3 days of no shaving transepidermal re-entry penetration will occur. If morning shaving is routine, the affected areas should be gently buffed or brushed the evening before with a toothbrush, a rough dry washcloth, or a Buf Puf ™ to loosen hairs about to embed.
Hair clippers will cut hair closely but not so close as to allow transfollicular penetration. Because razor shaving is much closer, clippers should be used at least twice daily to avoid a permanent ‘5 o’clock shadow.’
Powder chemical depilatories are not practical. They are messy to use, hard to mix accurately, difficult to remove rapidly, and, because they are so irritating, cannot be used more than every 3 days, which already allows PFB to recur. Lotion depilatories are much easier to apply and remove and, being less irritant, can be used every 2 days to produce a satisfactory cosmetic appearance.
Antibiotics are not necessary topically because this is a sterile foreign body reaction not a pyoderma. Irritants such as retinoic acid or glycolic acid may enhance lifting of hairs and diminish hyperpigmentation.
Several longer-wavelength long pulsed lasers (alexandrite, 810 nm diode, and Nd:YAG) or intense pulse light (IPL) sources combined with epidermal protective chilling devices can be used to produce dramatic long-lasting remission, even in Fitzpatrick types IV, V, and VI patients, and represent a breakthrough treatment for recalcitrant disease. Caution must be employed in dosage selection based on the patient’s underlying skin color, since the hyperpigmented papules themselves may act as highly absorbing hotspots not anticipated by overall lighter skin color and may develop visible burns. Hyperpigmentation may involute without specific bleaching agents as the inflammation subsides when hairs disappear. Otherwise strategies employing techniques for both epidermal and tattoo-like dermal pigmentation need to be attempted.
Skin biopsy in rare instances
K6hf gene analysis
No investigations are necessary for usual cases of PFB. As it is induced by hair manipulation, i.e., shaving or plucking, it is not associated with other diseases. Differentiation of true bacterial folliculitis requiring systemic antibiotics must sometimes be considered. Rarely, yeast folliculitis may mimic PFB. Careful clinical inspection and possibly skin biopsy should be performed to rule out granulomatous disease such as sarcoidosis or dental sinusitis in the presence of apparently hypertrophic or keloidal scars. Rarely, cyclosporine therapy may induce a pseudofolliculitis-like condition. Recent French literature cites necrotic folliculitis-like lesions and pathergy as common cutaneous presentations of Behçet syndrome; this ‘pseudofolliculitis’ is not the PFB of ingrowing hairs.
Norton S, Chesser R, Fitzpatrick J. Military Med 1991; 156: 369–71.
A man with hilar adenopathy had smooth firm purplish papules (lupus pernio) on his face and PFB in his beard area. Biopsies of papules of both the lupus pernio and the PFB revealed non-caseating granulomas consistent with sarcoidosis.
Liew H, Morris-Jones R, Diaz-Cano S, Bashir S. Clin Exp Dermatol 2012; 37: 800–1.
Case report of a 61-year-old Afro-Caribbean man with chronic folliculitis of his face and scalp complicated by Pseudomonas and enterococcal infection and resulting in papules mimicking keloids, all of which appeared after institution of oral minoxidil (for hypertension) with accompanying increased growth of hair, and ceasing only with termination of minoxidil therapy.
Pseudofolliculitis is not demonstrated clinically or histologically in this mistitled paper; folliculitis papillaris with pyoderma is a more appropriate diagnosis.
Coker L, Swain R, Morris R, McCall C. Cutis 2000; 66: 207–10.
A 42-year-old African-American man with AIDS had countless dome-shaped excoriated papules on his trunk, arms, and face, initially diagnosed as folliculitis (not pseudofolliculitis of ingrowing hairs) with biopsy-proven disseminated cutaneous cryptococcosis.
Lear J, Bourke JF, Burns DA. Br J Dermatol 1997; 136: 132–3.
A condition resembling keloid reactions in PFB is reported as an unusual reaction to cyclosporine.
Lally A, Wojnarowska F. Clin Exp Dermatol 2007; 32: 268–71.
Five cases of hyperplastic PFB in white patients with renal transplants and cyclosporine immunosuppression are reported with chin involvement in all, but two also had involvement of the nose and occiput, which is otherwise never seen.
The photographs reveal folliculitis papillaris not PFB.
Winter H, Schissel D, Parry D, Smith TA, Liovic M, Birgitte Lane E, et al. J Invest Dermatol 2004; 122: 652–7. Comment in: J Invest Dermatol 2004; 122: xi–xiii.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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