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Background
to pseudofolliculitis barbae or shaving bumps
Pseudofolliculitus of the beard usually occurs in people with very
tightly curled hair, particularly men of Hispanic or African origin
who are in the habit of shaving very closely. It is a chronic inflammatory
condition that manifests as skin papules and pustules.
Though not a serious medical problem, pseudofolliculitis of the
beard may have psychosocial implications for the people it affects.
There is really no complete cure for it for men who want a clean-shaven
look; only partial management of the problem is possible. Of late,
however, laser hair removal treatment has revolutionized the medical
therapy of pseudofolliculitis barbae and emerged as a successful
cure. However, not everyone is suitable for undergoing laser hair
removal.
Pathophysiology
of pseudofolliculitis barbae
Pseudofolliculitus of the beard (PFB) occurs mostly in adult black men. In
the U.S., anywhere between 10 – 80% of African-American men who shave
closely, like in the armed forces, suffer from this condition according to
various study reports. PFB can lead to scarring and chronic disfigurement
of the face. Sometimes it can also lead to secondary infections, hyper pigmentation
of the skin or keloid formation. Although it is found more commonly in men,
women with tightly curled hair may also suffer from this condition – especially
in the bikini area. Women are also more likely to be affected during the perimenopausal
period when hormone changes lead to enhanced hair growth, sometimes with a
more kinked shape, as a result of androgen hormone activity.
Pathogenesis
of pseudofolliculitis barbae
The hair follicles in people with tightly curled hair are curved,
with the concave side towards the epidermis. The follicle also lies
obliquely at an angle to the surface of the skin. When such hair
is shaved closely, the sharp tip of the shaved hair emerges from
the skin and reenters the skin surface as a result of their tendency
to coil tightly. Sometimes the method of shaving causes the hair
to be cut below the surface of the skin. In such cases, the sharpened
tip of the hair pierces the wall of the follicle itself. This is
called transfollicular penetration.
Extrafollicular penetration most often occurs when shaving with the newer
multiple blade razors. These are more likely to cause transfollicular penetration
as these often result in the hair being trimmed below the surface of the skin
(it is indeed a closer shave!). Single bladed razors are somewhat less likely
to cut hair below the surface of the skin, but there is still significant
risk of pseudofolliculitis barbae developing if the hair being shaved is tightly
coiled.
Clinical
manifestation of shaving bumps
Diagnosis of PFB can be made based on the location and type of
the lesions. The most common manifestation is in the form of papules
and pustules in the beard area. Other common sites are the anterior
neckline, the mandibular region, cheeks and chin.
The typical lesion is a flesh colored papule of 2 mm to 4 mm size,
often with a hair shaft in the middle. When the hair shaft is lifted
up gently (with a pick or tweezers), one end frees itself out of
the papule.
Secondary infection of the area can lead to pustules or abscess
formation. The surrounding skin area is sometimes grooved or has
a depressed pattern due to parallel hair growth. In chronic cases
of PFB, hyper pigmentation, scarring or keloid formation may occur.
In fact post inflammatory hyper pigmentation occurs in 90% of the
cases and is a major clinical finding in PFB.
Differential
diagnosis of pseudofolliculitis barbae
PFB needs to be differentiated from true folliculitis, acne vulgaris
and tinea barbae. In true folliculitis, flesh colored follicular
papules occur, but this condition disappears within 1 or 2 days
of shaving being stopped, whereas in PFB, the papules remain for
up to a week after discontinuing shaving. In PFB bacterial cultures
are usually negative, but true folliculitis yields positive bacterial
cultures.
In the case of acne vulgaris the lesions occur outside the hair
growing area and the presence of comedones are the other characteristic
feature. In tinea barbae, a scaly plaque is found which tests positive
for fungal culture.
Treatment
of pseudofolliculitis barbae
The first line of treatment for PFB is to prevent its occurrence.
Prevention of pseudofolliculitis barbae is always better than cure.
The first option is to discontinue shaving or hair removal. But
patients are usually not willing to wait for 2 to 6 weeks for the
complete cure to be effected. However, Strauss and Kligman observed
that the condition resolved automatically after about a month as
the natural tension of the hair that grows to a length of about
1 cm causes the hair to be released from the epidermis.
Other techniques to release the hair can be tried. These include
washing the beard with warm water and an antibacterial soap regularly.
A polyester web sponge or mildly abrasive washcloth provides the
necessary traction to dislodge the free end of the hair.
If shaving is absolutely necessary, the correct type of shaving
instrument and the right technique of shaving should be recommended.
Reducing the closeness of the shave is of primary importance. Multiple
blade razors should be discarded. Electric clippers are the best
instrument because they have a protective gap between the clipper
and the comb.
For those who do not desire the 1 mm stubble left with a clipper,
razors like the “Bumpfighter” razor designed with a
single blade, polymer coating and foil guard, is suggested. This
was manufactured specially for PFB patients. Shaving should be done
carefully to avoid nicks and cuts. The skin should be moistened
before shaving and a pre-shaving lotion applied. Care should also
be taken not to pull the skin taut while shaving. Shaving should
also be done in the direction of hair growth.
Use of chemical depilatories is an alternative to shaving recommended
for PFB patients. Barium sulphide powder and calcium thioglycolate
present in the depilatory creams lyse disulfide bonds in the hair
so that the trimmed edge has a feathered tip. The blunt tip helps
prevent reentry of the hair into the epidermis. The cream is applied
to the hair, left on for 5 to 15 minutes and then removed with a
wooden spatula. But most depilatory creams are malodorous and may
cause irritation, especially on the more sensitive facial skin,
so they cannot be used too frequently.
Effornithine hydrochloride cream is a recent product for hair removal.
This inhibits an enzyme responsible for cell division in hair, thereby
retarding hair growth. This might be useful for people with pseudofolliculitis
barbae.
Drugs
for treating pseudofolliculitis barbae
Topical agents applied to the affected area have helped in the
management of PFB and in reducing irritation. Hydrocotisone cream,
10% urea cream and lactic acid can help to reduce inflammation of
papular lesions.
Topically applied retinoids have helped in some cases. Tretinoin
or adapalene help to reduce hyperkeratosis arising from repeated
nicking of the follicular epithelium. Applications of alpha-hydroxyl
acids like glycolic acids helps to reduce the lesions caused by
PFB making the hair grow straighter, thereby preventing their re-entry
into the epidermis or follicular wall.
Severe cases of PFB may need to be treated with tropical and oral
antibiotics. Erythromycin, clindamycin and benzamycin reduce skin
bacteria and successfully treat secondary infections.
Where abscess formation is indicated, tetracycline is a common
drug of choice in such cases for treating both gram positive and
gram negative organisms.
Chemical peels with glycolic and salicylic also act in a similar
fashion as retinoids. Treating with salicylic acid helps to reduce
the inflammatory lesions and decreases the hyper-pigmented macules.
Liquid nitrogen used as a cooling spray, also has a light peeling
effect but must be used with caution as it might lead to hyper pigmentation
due to destruction of melanocytes.
Surgical
care of pseudofolliculitis barbae
Electrolysis and surgical depilation of hair has also been tried.
Electrolysis of the beard is not generally recommended as it may
result in hyper pigmentation. Sometimes a papular development or
inflammation occurs after the procedure. Conversely, electrolysis,
waxing or tweezing can sometimes give rise to further PFB.
The only long term solution to PFB seems to be permanent removal
of hair follicles by hair removal lasers. Melanin acts as the chromophore,
which is targeted for removing the hair follicles. After a treatment
with diode laser, subjects with PFB showed a 50% decrease in hair
density and a delay of 3 to 8 weeks in further hair growth.
Laser hair removal though, may have certain side effects. As melanin
is the target chromophore, natural skin pigments may be destroyed
by the process – especially in dark skinned people. Physicians
therefore have to decide on the laser parameters of the individual
carefully before embarking on the treatment. Not everyone is suitable
for undergoing laser hair removal and and the decision largely rests
on skin color. Erythema, crusting blistering or scarring may also
occur as side effects. Care should be taken for proper laser techniques
to minimize the side effects.
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barbae or shaving bumps references
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