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Back to: eMedicine Specialties > Dermatology > Diseases Of The Adnexa Pseudofolliculitis of the Beard
Last Updated: August 26, 2003
Synonyms and related keywords: PFB, pseudofolliculitis barbae, pili incarnati, folliculitis barbae
traumatica, chronic scarring pseudofolliculitis of the negro beard, shaving bumps, razor bumps, AUTHOR INFORMATION
Section 1 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography Author: Thomas G Greidanus, MD, Staff Physician, 4th Infantry Division, 3rd
Brigade Combat Team, Evans US Army Hospital, Fort Carson
Coauthor(s): Beth Honl, MD, Chief, Department of Dermatology, Evans US Army
Editor(s): Leonard Sperling, MD, Chair, Professor, Department of Dermatology,
Uniformed Services University of the Health Sciences; Richard Vinson, MD,
Chief, Department of Dermatology, William Beaumont Medical Center; Jeffrey
Meffert, MD, Program Director, Dermatology Service, San Antonio Uniformed
Services Health Education Consortium; Joel M Gelfand, MD, MSCE, Director,
Clinical Studies Unit, Assistant Professor, Department of Dermatology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Hospital; and Dirk M Elston, MD, Consulting Staff, Department of Dermatology, Geisinger
INTRODUCTION
Section 2 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures 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. It can also affect some white men and hirsute black women. Pseudofolliculitis pubis is a similar condition occurring after pubic hair is shaved. Pathophysiology: Two mechanisms are involved in the pathogenesis of PFB: (1)
http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD 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 PRB with transfollicular penetration. Frequency:
z In the US: About 10-80% of adult black men have PFB, particularly those
who shave closely on a regular basis. It is a significant problem in black men in the military where regulations require a clean-shaven face. Mortality/Morbidity: Although usually not regarded as a serious medical problem,
PFB can cause cosmetic disfigurement. The papules can lead to scarring,
postinflammatory hyperpigmentation, secondary infection, and keloid formation.
Race: PFB is found mostly in black men.
Sex: Men with facial hair comprise most patients, although hirsute women can get
PFB as well. Both sexes can get pseudofolliculitis pubis.
Age: PFB affects men with facial hair (postpuberty).
CLINICAL
Section 3 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography History:
z Patients complain of a painful acneiform eruption that occurs after shaving. z The patient’s shaving history, including the method and the frequency, may z 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. Physical:
z 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 http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD z These inflammatory papules are seen in shaved areas adjacent to the z Pustules and abscess formation can occur from secondary infection. z Postinflammatory hyperpigmentation, scarring, and keloid formation may occur in chronic or improperly treated cases. Causes: African Americans are genetically predisposed to PFB 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.
DIFFERENTIALS
Section 4 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography Acne Vulgaris Folliculitis Sarcoidosis Tinea Barbae
Other Problems to be Considered:
Acne keloidalis nuchae (may coexist with PFB) Section 5 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography Lab Studies:
z A clinical diagnosis can usually be made. Procedures:
z A case of sarcoid infiltrating lesions of PFB has been documented. Biopsy may be perfor z See Medical Care and Deterrence/Prevention for a discussion of shaving and hair-releas Histologic Findings: The penetrating hair causes invagination of the epidermis with inflamma
intraepidermal abscesses. With penetration of the dermis, the epidermis grows down to try to e
the hair, and severe inflammation, abscess formation, and a foreign-body giant cell reaction oc
tip of the hair.
http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD TREATMENT
Section 6 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography Medical Care:
z Chemical depilatories work by breaking the disulfide bonds in hair, which results in the ha broken off bluntly at the follicular opening. { Barium sulfide powder depilatories of about 2% strength can be made into a paste and applied to the beard area. This paste is removed after 3-5 minutes. { Calcium thioglycolate preparations come as powder, lotions, creams, and pastes. T mercaptan odor is often masked with fragrance. In rare cases, this fragrance can callergic reaction. Calcium thioglycolate preparations take longer to work and are lefminutes; chemical burns result if left on too long. { Chemical depilatories should not be used every day because they cause skin irritat 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 pirritating. Several products are available; therefore, trying a different product is encoone depilatory proves to be unacceptable. z Topically applied tretinoin (Retin-A) has shown promise for some patients. When used ni alleviates hyperkeratosis. It may remove the thin covering of epidermis that the hair becoembedded in upon emerging from the follicle. z Mild topical corticosteroid creams reduce inflammation of papular lesions. z For severe cases of PFB with pustules and abscess formation, topical and oral antibiotic { Topical antibiotics may successfully reduce skin bacteria and treat secondary infec topicals include erythromycin, clindamycin, and Benzamycin. Applying one of theseonce or twice per day is effective. Benzoyl peroxide applied topically once a day is effective in reducing bacterial populations. It should be used sparingly and may be sensitive skin. It is a good first-line topical agent for persons with oily skin. Benzamcombination of erythromycin and benzoyl peroxide. A once daily application has theof both agents. { If pustules or abscess formation is evident, an oral antibiotic is indicated. Tetracycli common choice for a systemic antibiotic. Similar to a standard acne regimen, a dosmg twice a day used initially for 1-3 months is often effective. Surgical Care: Newer hair removal lasers may have a role in the treatment of PFB. The proble
most laser and high-intensity light source hair removal modalities is that the natural skin pigme
damaged by the laser because melanin in the hair shaft is the target chromophore. Devices be
studied at this time may avoid this depigmenting complication.
http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD Diet: No dietary therapies for PFB have proven effective, and no dietary triggers of the conditio
been identified.
MEDICATION
Section 7 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography Hydrocortisone cream is effective in reducing inflammation. Topical and oral antibiotics are usesecondary infection is evident. Tretinoin has shown promise in early PFB. Chemical depilatoriepreferential to shaving for some patients. Drug Category: Chemical depilatories -- These agents are effective alternatives to shavinpatients. They work by breaking disulfide bonds in hair follicles. Barium sulfide -- A fast-acting depilatory powder that Drug Name
Adult Dose
Apply thin paste and leave on for 3-5 min Pediatric Dose
Contraindications
Interactions
C - Safety for use during pregnancy has not been Pregnancy
Pregnancy class is not listed; product is fast acting Precautions
and can cause a chemical burn if left on too long; has foul odor and is poisonous if ingested Calcium thioglycolate -- Effective depilatory that is left Drug Name
Adult Dose
Pediatric Dose
Contraindications
Interactions
C - Safety for use during pregnancy has not been Pregnancy
Pregnancy class is not listed; chemical burn can Precautions
result if preparation is left on too long Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive and shoall likely pathogens in the context of the clinical setting. Topical preparations reduce bacterial pand secondary infection. Tetracycline (Achromycin V, Sumycin) -- Used orally to treat secondary infection. Treats gram-positive and gram-negative organisms as well as mycoplasmal, Drug Name
chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits. Adult Dose
http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD Pediatric Dose
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid Documented hypersensitivity; severe hepatic Contraindications
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral Interactions
contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants Pregnancy
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal and/or liver impairment; consider drug serum level determinations in prolonged therapy; Precautions
tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines Erythromycin (T-Stat) -- 2% topical solution. Inhibits bacterial growth, possibly by blocking dissociation of Drug Name
peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. Adult Dose
Pediatric Dose
Contraindications
Additive irritation with other topical agents (eg, Interactions
Pregnancy
B - Usually safe but benefits must outweigh the risks. For external use only; keep away from eyes and Precautions
Drug Category: Retinoids -- These agents decrease the cohesiveness of abnormal hyperprkeratinocytes, and they may reduce the potential for malignant degeneration. They modulate kdifferentiation. They have been shown to reduce the risk of skin cancer formation in patients wundergone renal transplantation. Tretinoin (Retin-A) -- Inhibits microcomedo formation and eliminates existing lesions. Makes keratinocytes in sebaceous follicles less adherent and easier to Drug Name
remove. Applied topically, reduces outbreaks of mild PFB. Available as 0.025%, 0.05%, and 0.1% creams. Also available as 0.01% and 0.025% gels. Adult Dose
Apply topically 2 times/wk to qhs; titrate to effect http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD Pediatric Dose
Contraindications
Documented hypersensitivity; eczema; sunburn Toxicity increases with coadministration of benzoyl peroxide, salicylic acid, and resorcinol; avoid topical Interactions
sulfur, resorcinol, salicylic acid, other keratolytics, abrasives, astringents, spices, and lime C - Safety for use during pregnancy has not been Pregnancy
May take several wk for skin to adapt to irritative effect; by starting application every wk and slowly increasing to qhs noncompliance from warmth and Precautions
redness is decreased; avoid eyes and mucous membranes; minimize exposure to sun and UV light; do not apply to mucous membranes, mouth, and angles of nose Drug Category: Corticosteroids -- These agents are used to reduce inflammation and irritaagents have anti-inflammatory properties and cause profound and varied metabolic effects. Ththe body’s immune response to diverse stimuli. Hydrocortisone (Cortaid) -- 1% cream. Adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Drug Name
Has mineralocorticoid and glucocorticoid effects, resulting in anti-inflammatory activity. Effective when used topically on a short-term basis. Adult Dose
Pediatric Dose
Documented hypersensitivity; viral, fungal, and Contraindications
Interactions
C - Safety for use during pregnancy has not been Pregnancy
Prolonged use, applying over large surface areas, applying potent steroids, and using occlusive dressings may increase systemic absorption of Precautions
corticosteroids and may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria FOLLOW-UP
Section 8 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography Further Outpatient Care:
z Outpatient evaluation and patient education is effective. With proper techniques, transfol http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD extrafollicular penetration can be minimized. Deterrence/Prevention:
z Hair-releasing procedures and shaving should be performed after a shower to hydrate an both the skin and the hair. Subsequent shaving results in a more dull, rounded tip to the is less likely to reenter the skin. z Wash the beard with a face cloth, a wet sponge, or a soft-bristled toothbrush with a mild several minutes using a circular motion. This technique helps to dislodge stubborn tips. z 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 dthe skin. z Patients with PFB may use razors if single-edged, foil-guarded, safety razors are used. D triple-bladed razors shave too closely and should not be used. Commercially available forazors have about 30% of the blade covered by foil, which prevents the blade from shavitoo closely. z Electric razors have acceptable results if used properly. The recommended technique wi headed rotary electric razor is to keep the heads slightly off the surface of the skin and toa slow, circular motion. Do not press the electric razor close to the skin or pull the skin tathis results in too close of a shave. Some electric razors have "dial in" settings for the clothe shave. These may be effective if kept off of the closest settings. z Electric clippers are effective for resistant cases of PFB. With clippers, 1- to 2-mm stubbl left on the face. The tendency to shave too closely is reduced with this method, making iteffective. The appearance of stubble may be cosmetically unacceptable for some patient Complications:
z Although usually not regarded as a serious medical problem, PFB may cause cosmetic disfigurement. The papules may lead to scarring, postinflammatory hyperpigmentation, sinfection, and keloid formation. Prognosis:
z No cure exists, but effective treatment is available. If the patient is able to grow a beard, problem usually disappears (except for any residual scarring). Patient Education:
z Instruct the patient to stop shaving for 3-4 weeks. This gives adequate time for the hair fo grow to a length where ingrown hairs will spring free. MISCELLANEOUS
Section 9 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD Special Concerns:
z PFB is of particular concern in persons in the military. Enforcement of a clean-shaven fac with this condition can cause scarring, hyperpigmentation, secondary infection, and keloiformation. The lack of understanding of this disease has created tension and hostility betsoldiers and their chain of command. Proper education on shaving methods and treatmeincluding judicious breaks from shaving (no shaving profiles), is essential. PICTURES
Section 10 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography Caption: Picture 1. Pseudofolliculitis barbae on the neck of a black man.
Picture Type: Photo
BIBLIOGRAPHY
Section 11 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography z Alexander AM: Evaluation of a foil-guarded shaver in the management of pseudofolliculit Cutis 1981 May; 27(5): 534-7, 540-2[Medline]. z Alexander AM, Delph WI: Pseudofolliculitis barbae in the military. A medical, administrati social problem. J Natl Med Assoc 1974 Nov; 66(6): 459-64, 479[Medline]. z Brauner GJ, Flandermeyer KL: Pseudofolliculitis barbae. Medical consequences of interr friction in the US Army. Cutis 1979 Jan; 23(1): 61-6[Medline]. z Brown LA Jr: Pathogenesis and treatment of pseudofolliculitis barbae. Cutis 1983 Oct; 32 z Childs ND: Tretinoin, hydrocortisone cream controls PFB. Skin and Allergy News 1999; 3 z Coquilla BH, Lewis CW: Management of pseudofolliculitis barbae. Mil Med 1995 May; 16 z Crutchfield CE 3rd: The causes and treatment of pseudofolliculitis barbae. Cutis 1998 Ju z Galaznik JG: A Pseudofolliculitis Barbae clinic for the black male who has to shave. J Am z Halder RM: Pseudofolliculitis barbae and related disorders. Dermatol Clin 1988 Jul; 6(3): z Kligman AM, Mills OH Jr: Pseudofolliculitis of the beard and topically applied tretinoin. Ar Dermatol 1973 Apr; 107(4): 551-2[Medline]. z Nidecke A: Saving face: help black men avoid pseudofollicultis barbae. Skin and Allergy z Olsen EA: Methods of hair removal. J Am Acad Dermatol 1999 Feb; 40(2 Pt 1): 143-55; q http://www.emedicine.com/derm/topic354.htm eMedicine - Pseudofolliculitis of the Beard : Article by Thomas G Greidanus, MD Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. T
editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted with
standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors,
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