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Pseudofolliculitis barbae

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Pseudofolliculitis barbae

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

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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.

Management strategy

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:

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.

Specific investigations

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.

An unusual Ala12Thr polymorphism in the 1A alpha-helical segment of the companion layer-specific keratin K6hf: evidence for a risk factor in the etiology of the common hair disorder pseudofolliculitis barbae.

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.

The authors identify a family with two curly-haired white males with PFB and one straight-haired non-PFB-afflicted female with an unusual dominantly inherited single-nucleotide polymorphism, which gives rise to a disruptive Ala12Thr substitution in the 1A α-helical segment of the companion layer-specific keratin K6hf of the hair follicle. In transfected cells this gene seems to be disruptive of filament assembly. A test group of 100 black people, 82% of whom had PFB, and 110 white people (a very high 18% of whom had PFB) showed this unusual gene in 9% of whites but only 36% of blacks (97% of whom had PFB).

The authors somehow conclude that this gene represents a significant genetic risk factor for PFB.

First-line therapies

image Beard growth D
image Razor shaving technique D
image Hair clippers D
image Chemical depilatories D
image Adjunctive hair extraction D

Pseudofolliculitis barbae. Medical consequences of interracial friction in the US Army.

Brauner G, Flandermeyer K. Cutis 1979; 23: 61–6.

PFB is a minor disease affecting only, and almost all, black people who shave. Due to the continued requirement of the US Army for clean-shaven faces, significant interracial turmoil and animosity has been aroused. Unclear standards of care of the disease and haphazard policing of shaving habits led to a chaotic process, with effective dermatologic care almost paralyzed by the hostile parties. During the Vietnam War era randomly approached lower-ranking enlistees and draftees were much more likely to complain about their disease, even if minor, and were more likely to refuse to shave and be unkempt even without permission to grow a beard (in contravention of Army regulations). Career black enlistees are likely to underreport the severity of their disease and not seek medical help, possibly because of fear of continuous harassment and inability to be promoted by their superiors. Lotion depilatories or hair clippers, combined with routine lifting of ingrown hairs, are the most effective treatments, though complete cessation of shaving is required first.

Second-line therapies

image Retinoic acid E
image Glycolic acid B
image Topical clindamycin A

Twice-daily applications of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae.

Cook-Bolden F, Barba A, Halder R, Taylor S. Cutis 2004; 73: 18–24.

Seventy-seven men with 16–100 combined papules and pustules on the face and neck were randomized to receive twice-daily benzoyl peroxide 5%/clindamycin 1% (BP/C) gel or vehicle for 10 weeks; 77.3% of the participants were black. All patients were required to shave at least twice a week with a disposable Bumpfighter razor, and to use a standardized shaving regimen. At weeks 2, 4, and 6, mean percentage reductions from baseline in combined papule and pustule counts were statistically significantly greater with BP/C gel than with vehicle, but for both were >50% by 10 weeks, particularly in black men. There was a significant change in non-black men, but no difference between test and controls.

Although 77% of test patients thought they were much better compared to 47% in the control vehicle group, the authors do not explain the remarkable improvement in the control group, nor why or how they assume their test product alone ‘worked.’

Third-line therapies

image Laser depilation A
image Surgical depilation C

Comparative evaluation of long pulse alexandrite laser and intense pulsed light systems for pseudofolliculitis barbae treatment with one year of followup.

Leheta T. Indian J Dermatol 2009; 54,364–8.

Twenty male patients allegedly Fitzpatrick types II–IV with pseudofolliculitis were treated in a double-blind split-face study by Alexandrite laser on one side and IPL on the other while continuing to shave or clip the bearded face. The alexandrite was 755 nm with a 15 mm spot size and was operated at 3 ms eventually at 16–18 J/cm2 while the IPL had a 610–1200 nm filter and a 50 mm × 15 mm spot size and was operated at 12–15 J/cm2, both at 4- to 6-week intervals for four sessions then 4- to 8-week intervals. Both techniques improved the condition but the alexandrite laser required an average of seven sessions to reach about 80% improvement in papule count and hyperpigmentation, while the IPL-treated side needed 10 to 12 sessions to reach about 50% improvement. Both techniques, however, showed some relapse at 1 year following end of treatments, the IPL more so.

The differences seen may be due to the low settings for both devices; fluences of 20–30+ J/cm2 are frequently required for effective laser- or IPL-induced follicular fatigue or destruction especially in type II–IV skin.

Low-fluence 1064-nm laser hair reduction for pseudofolliculitis barbae in skin types IV, V, and VI.

Schulze R, Meehan K, Lopez A, Sweeney K, Winstanley D, et al. Dermatol Surg 2009; 35: 98–107.

Twenty-two patients with PFB refractory to conservative therapy received five weekly treatments (unlike the customary every 5 weeks) over the anterior neck using a 1064 nm Nd:YAG laser with a 10 mm spot size set at 12 J/cm2 and pulse duration 20 ms. Eleven patients demonstrated 83% improvement.

The study was an attempt to reduce energy levels because of high incidence of intolerance to pain in standard settings. The effects were clear but only temporary, and worsening of PFB after switching to a razor blade as a shaving device suggests an imperfect solution since most blacks shave with razors.

Topical eflornithine hydrochloride improves the effectiveness of standard laser hair removal for treating pseudofolliculitis barbae: a randomized, double-blinded, placebo-controlled trial.

Xia Y, Cho S, Howard R, Maggio K. J Am Acad Dermatol 2012; 67: 694–9.

Twenty-seven patients (24 black, three Caucasian) with Fitzpatrick type II–VI skin and afflicted with PFB were enrolled in a double-blind split-neck study comparing four monthly treatments with Nd:YAG laser with 10 mm spot and at 25–30 J/cm2 with 20–30 ms pulse duration with and without twice daily application of 13.9% eflornithine cream. Shaving was continued throughout the study. A very significant decrease in countable hairs and papules was evident after only two treatments and almost no papules evident at 16 weeks; the eflornithine side was moderately better at each stage. Pain measures were not discussed

This promising study for shortening treatment course had a much too short a follow-up period, i.e., immediately at the end of 16 weeks of treatment. Permanence was not ascertainable. It was peculiar that the eflornithine side responded more quickly when the medication should be causing a progressively smaller target for the laser suggesting a more dramatic effect on hair production than just the caliber of hair.

Modified superlong pulse 810 nm diode laser in the treatment of pseudofolliculitis barbae in skin types V and VI.

Smith E, Winstanley D, Ross E. Dermatol Surg 2005; 31: 297–301.

Ten of 13 patients with type V or VI skin treated with superlong-pulse 810 nm diode laser at 2-week intervals three times with a mean 29 J/cm2 and 438 ms for type V and 26 J/cm2 at 450 ms for type VI skin, and then followed up to only 3 months, showed clinical improvement of PFB papules which was statistically significant. The authors note that the 26 J/cm2 maximum tolerable dose may not be sufficient to cause long-term reduction in hair growth. The follow-up of the study was not long enough to determine such reduction either. The authors claim that the ratio of minimal damaging fluence to minimum effective fluence in very dark skin was 1.2 : 1, versus the safer 1.5–2 : 1 for long-pulse Nd:YAG laser for PFB.

Treatment of pseudofolliculitis barbae using the long-pulse Nd:YAG laser on skin types V and VI.

Weaver S, Sagaral E. Dermatol Surg 2003; 29: 1187–91.

Twenty subjects with Fitzpatrick type V and VI skin and PFB on the neck or mandible were given two 2 cm × 2 cm treatments with Nd:YAG laser and 10 mm spot size at 40–50 ms and 24–40 J/cm2 3 to 4 weeks apart, assessed by photographic papule/pustule and hair counts at 1, 2, and 3 months after the final treatment and compared to a neighboring untreated site. The 76–90% reduction in the number of papules/pustules was statistically significant. Hair reduction of 80% 1 month after testing diminished to 23% by 3 months.

Although side effects were noted as transient and without blistering, the two illustrated patients both show scarring.

Surgical depilation for the treatment of pseudofolliculitis or local hirsutism of the face: experience in the first 40 patients.

Hage J, Bouman F. Plast Reconstruct Surg 1991; 88: 446–51.

Forty patients, all but three of whom were Caucasian, were operated on over a 15-year period for local hirsutism (n=24), pseudofolliculitis (n=11), and beard growth (n=12) in transgender procedures. The skin of the affected areas was incised and everted in a dermal–subcutaneous plane and the hair bulbs were excised. Marked diminution of hair numbers occurred, but 15 patients required further electrolysis. Side effects were significant, with wound edge necrosis in eight, seroma or hematoma in eight, and significant subcutaneous scar formation in 15, which was later preventable by postoperative long-term (at least 3 months) pressure bandages. See also Comments in Plast Reconstruct Surg 1992; 90: 332–3.

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