INSIGHTS INTO ETHNIC SKIN AND HAIR
Getting to the Root of
Pseudofolliculitis Barbae
An interesting history to a common disorder — plus a look at the
most effective treatments.
By Heather Woolery-Lloyd, M.D.
F
irst reported in 1908, pseudofolliculitis barbae (PFB) is a common inflammatory condition caused by ingrown hairs in the beard
area of African-American and Hispanic men who
have tightly coiled hair. Fox first noted the condition, and it was later described as pseudofolliculitis
of the beard by Strauss and Kligman in 1956.1,2
Present in up to 83% of African-American men,
this condition is characterized by inflamed
papules and occasional pustules in the beard after
close shaving.3
The neck is the most commonly affected site
although the ingrown hairs and resultant inflammation can be seen anywhere on the beard. Post-inflammatory hyperpigmentation, scarring, and keloid formation may also occur. African-American women with
hirsutism most commonly present with PFB localized
to the chin after tweezing, shaving or electrolysis of the
hairs.4 Pseudofolliculitis is also seen after shaving other
areas of the body and is often observed in the bikini
and axilla of women.
In the early 1970s, PFB became a significant problem
in African-American military personnel because the
Army enforced strict shaving requirements. Some servicemen who suffered from PFB were exempt from the
no-beard requirements however, many feared the
social stigma associated with beards in the army at that
time.3 As a result, the Army has sought to improve education on the cause and treatment of PFB in military
personnel.
Even today, PFB is a significant dermatologic complaint for soldiers and for African-American patients in
26
S
K I N
& A
G I N G
• M
AY
2003
other professions in which a closeshaven appearance is required.
CURVED HAIR FOLLICLES TO BLAME
This condition is due to the unique
curvature of the hair follicle in affected
patients. In contrast to Asian and most
Caucasian hair in which the hair follicle
is straight, in African-Americans the hair
follicle is curved. Due to the curvature
of the follicle, and the tightly coiled
hairs, ingrown hairs are prominent. In
African-American patients, the beard
hair initially grows parallel to the skin
surface so that when it is shaved, it’s cut
at a sharp oblique angle.2 After close
shaving, the sharply edged hair either re-enters the surface of the skin (extrafollicular penetration) or transects the follicle (transfollicular penetration) to form
the ingrown hair. This ingrown hair elicits an inflammatory response, which leads to the papules and occasional pustules observed clinically. On pathology, neutrophilic inflammation predominates in the epidermis.
As the hair penetrates the dermis, inflammation
increases and downgrowth of the epidermis occurs in
an attempt to encircle the hair. A foreign body giant cell
reaction can occur at the end of the penetrating hair
leading to granulomas and fibrosis.2
SIMILAR CONDITIONS
The differential diagnosis of this condition includes a
bacterial folliculitis of the beard also known as sycosis
vulgaris. This condition presents with pustules of the
beard that grow Staphylococcus aureus when cultured.
Tinea barbae can also present with follicular papules
and pustules on the beard. Clinical features range from
a superficial crusted pustular folliculitis to intensely
inflamed boggy nodules
with abscess formation.
Fungal culture of these
lesions grow Trichophyton
species, most commonly
T. rubrum and T. verrucosum.
(For more information on
tinea barbae, see this
month’s “Derm Dx” column, which begins on page
86.) Additionally, some
patients develop a traumatic folliculitis after close shaving with scattered 1-mm to
2-mm
pink
papules.
However, this condition,
commonly referred to as
“razor burn,” is transient,
resolves within 1 to 2 days,
and isn’t caused by ingrown
hairs.5
ESTABLISHING PROPER
This patient exhibits a typical case of pseudofolliculitis barbae, which can commonly
SHAVING TECHNIQUES
There are many different occur in men who shave their heads.
approaches to the treatment of PFB. If patients are able to stop shaving com- troversial. Although, if stubborn ingrown hairs are
pletely, the condition resolves within several weeks, how- removed with care, this practice is helpful. The concern
ever, in most patients this isn’t a reasonable option.
with this approach is that patients can often probe too
In patients with mild to moderate disease, modifica- aggressively, leading to further inflammation and section of shaving techniques can often alleviate symp- ondary infection. A less invasive, but probably less effectoms. Many practitioners advocate the use of electric tive method of releasing hairs is with a soft-bristled
razors or clippers because these devices don’t allow for toothbrush or a rough washcloth.
such a close shave, helping to prevent ingrown hairs
■ Using depilatory creams. Other methods of hair
from forming. For patients who opt to use convention- removal include depilatory creams. Depilatory creams
al razors, the following suggestions can help to prevent can be effective and in preventing ingrown hairs.
ingrown hairs and resultant PFB:
However, they’re often irritating for many patients so
■ Choosing the best razor. After a warm shower or after their use in PFB is somewhat limited.
the patient soaks his skin with warm water, he should
use a foil-guarded razor to shave in the direction of AFTER SAFE SHAVING HABITS ARE IN PLACE
hair growth, which generally is downward. Foil-guardAfter appropriate shaving techniques have been
ed razors were developed specifically for PFB and have established, other topical medications can be utilized
a foil guard covering approximately 30% of the blade. in the treatment of PFB. The role of these medications
This prevents close contact of the blade with the skin is to prevent hyperkeratosis allowing for superficial
allowing for a less close shave.6
ingrown hairs to be released from the skin.
■ Avoiding skin stretching. Additionally, patients
Topical retinoids have been an effective adjunct in
should avoid stretching the skin while shaving as this treating PFB.7 Alpha and beta hydroxy acids have also
leads to a closer shave and increases the chances of been utilized to decrease hyperkeratosis.8 Topical
developing ingrown hairs.
antibiotics are sometimes prescribed to prevent super■ Replacing razors. Razors should be replaced fre- ficial infections. For patients who have significant secquently, and double bladed razors should be avoided. ondary infection, oral antibiotics can be used.
■ Avoiding certain hair removal methods. The use of
Although the above recommendations are helpful in
needles or toothpicks to remove ingrown hairs is con- mild to moderate cases, patients with severe disease
S
K I N
& A
G I N G
• M
AY
2003 27
ETHNIC SKIN
treat personnel with PFB.
The most often affected
areas of PFB, such as the anterior neck and upper cheeks,
are the most appropriate
areas to treat with laser hair
removal because the laser
removes the affected hairs
and redefines a new hairline.
However, limitations of
laser hair removal occur
when central areas of the
beard are involved. For
example, if a man has PFB
prominent on his central
cheeks or chin, the resultant alopecia after treatment may look unnatural
when surrounded by normal hairs.
One way to combat this
problem is to use lower energies so that just the ingrown
hairs are removed, avoiding
Following treatment, this patient had significant clearing of his
pseudofolliculitis barbae.
permanent alopecia. Other
limitations include cost and
access to these lasers.
often persist with symptoms despite strict adherence to
Overall, new laser technology allows safe and effective
treatment recommendations.
laser hair removal in darker-skinned patients. This techUntil recently, we had little more to offer these nology has provided an effective treatpatients. Hair removal lasers now offer these patients ment option with dramatic results for
an alternative to laborious grooming practices to con- patients with PFB. ■
trol their PFB.
Dr. Woolery-Lloyd is the Director of
LASER HAIR REMOVAL: A CURE FOR PFB?
Ethnic Skin Care for the Division of
With the introduction of laser hair removal, the Cosmetic Dermatology in the Department of
treatment of PFB has dramatically changed. The long- Dermatology at the University of Miami.
pulsed diode laser was the first reported laser to have
excellent results when treating PFB.9 Its only limita- References
1. Fox H. Observations on skin diseases in the Negro. J Cutan Dis. 1908;26:67-79.
tions are in very dark-skinned type VI patients where 2. Strauss JS, Kligman AM. Pseudofolliculitis of the beard. Arch Dermatol
1956;74:533-42.
the risk of post-inflammatory pigment alteration is still Syphilol
3. Brauner G. Flandermeyer K. Pseudofolliculitis barbae: Medical
possible. With the introduction of the long pulsed Consequences of Interracial friction in the US Army. Cutis. 1979;23:61-66.
4. Perry PK. Cook-Bolden FE. Rahman Z. et al. Defining pseudofolliculitis
Nd:YAG laser for hair removal, patients with barbae in 2001: a review of the literature and current trends. J Am Acad
Fitzpatrick skin types V and VI have an option for safe Dermatol. 2002;47(2 Suppl Understanding):S113-9.
5. Halder R. Pseudofolliculitis barbae and related disorders. Dermatol Clinics.
and effective treatment for their PFB.10
1988;6(3):407-412.
Results can be seen as early as 3 weeks after the first 6. Alexander AM. Evaluation of the foil-guarded shaver in the management
of pseudofolliculitis barbae. Cutis. 1981;27(5):534-47, 540-2.
treatment. Additionally, after as few as two to three 7. Kligman AM. Mills OH. Jr. Pseudofolliculitis of the beard and topically
tretinoin. Arch Dermatol. 1973; 107(4):551-2.
treatments, patients report complete resolution of applied
8. Perricone NV. Treatment of pseudofolliculitis barbae with topical glycolic
papules. This is primarily because the initiating factor acid: a report of two studies. Cutis. 1993; 52(4):232-5.
Greppi I. Diode laser hair removal of the black patient. Lasers in Surgery
— the hairs — has been removed. The results with 9.
and Medicine. 2001;28(2):150-5.
laser hair removal in the treatment of PFB are so sig- 10. Ross EV. Cooke LM. Timko AL. Overstreet KA. Graham BS. Barnette DJ.
of pseudofolliculitis barbae in skin types IV, V, VI with a long
nificant that many military hospitals throughout the Treatment
pulsed neodinymium:yttrium aluminum garnet laser. J of Am Acad Dermatol.
country have purchased the long-pulsed Nd:YAG to 47(2):263-270.
28
S
K I N
& A
G I N G
• M
AY
2003