Pseudofolliculitis Barbae: Prevention and Treatment

US Pharm. 2016;41(10):37-40.

ABSTRACT: Pseudofolliculitis barbae (PFB), also known informally as razor bumps, is a common, chronic, inflammatory skin condition that occurs as a result of shaving, mainly in men of African descent. PFB is usually characterized by small, painful papules and pustules, but it may progress to scarring and keloid formation in some individuals. Most patients can successfully manage PFB by altering their grooming habits and using available topical and systemic treatment options. If results of other anti-PFB treatments are unsatisfactory, surgical intervention with laser therapy provides a viable option that could result in a cure.

Pseudofolliculitis barbae (PFB) (informally referred to as razor bumps) is a common, chronic, inflammatory skin condition that develops primarily as a result of shaving. Usually occurring in the beard area in men, PFB is characterized by painful, pruritic, erythematous papules and pustules that are typically 2 to 5 mm in diameter.¹ Other areas of the body that are frequently shaven may also be affected, including the axillae, scalp, nape of the neck, and pubic region.²

PFB can occur in any ethnic group; however, individuals with tightly coiled hair (e.g., those of African descent) are predisposed to the condition. It is estimated that 45% to 94% of all African American men will experience PFB at some point during their lifetime.¹ Hispanic, Asian, and Middle Eastern men are frequently affected as well. Some women may develop PFB, especially those with hirsutism or those who routinely shave their bikini area.^3,4 Although PFB is not life-threatening, hypertrophic scarring, postinflammatory hyperpigmentation (PIH), and keloid formation may occur in chronic or severe cases, resulting in cosmetic disfigurement.⁵

Pathogenesis

The pathogenesis of PFB is thought to be multifactorial. However, transfollicular penetration and extrafollicular penetration have been identified as the two primary processes responsible for the initial development of the PFB lesion (FIGURE 1).³ Transfollicular penetration occurs when the hair tip fails to exit through the epidermal layer and instead curves downward and continues to grow, eventually piercing the dermis, which causes an inflammatory reaction.⁶ Pulling the skin taut while shaving, using tweezers to pluck hair, and shaving with multiple-blade razors that leave the resultant hair tip in the follicle below the skin’s surface can lead to transfollicular penetration. Extrafollicular penetration is likely to develop after the use of a single-blade razor that cuts the hair shaft at the surface of the epidermis. The freshly cut hair, now with a sharpened tip, curls back into the epidermis a short distance away from the follicle and continues to grow downward, penetrating the epidermal layer. Similar to what takes place with transfollicular penetration, a foreign-body inflammatory reaction ensues, causing pain, inflammation, and the classic PFB lesion.⁵

Prevention and Management

PFB can be difficult to treat; however, with appropriate grooming techniques and available treatment options, the condition can be successfully managed in most patients. Since PFB is a foreign-body inflammatory reaction caused by transfollicular and/or extrafollicular penetration, initial therapy should be aimed at preventing these two processes. All patients with PFB should first be advised to stop shaving the affected area for a minimum of 4 weeks.^7,8 It is believed that, if the hair is allowed to grow continuously, ingrown hairs caused by transfollicular penetration will ultimately break through the overlying epidermal cover and come to the surface. In addition, hairs that have reentered the epidermal layer through extrafollicular penetration should naturally release from the epidermis after they have had time to grow to a length of approximately 10 mm.⁴ It has been reported that most PFB papules and pustules will disappear after 1 month of continuous hair growth.⁹ If letting the hair grow is not a feasible option, patients should be advised to use electric clippers, single-edged razor blades, or chemical depilatories for grooming.

Shaving: Patients who prefer to shave should be instructed to use barber-style electric clippers with an adjustable guard or comb attachment that maintains a hair length of 1 to 3 mm (known as a five-o’clock shadow). Patients desiring a closer shave may need to use a razor blade. Single-edged razor blades that contain a protective foil guard to prevent the hair from being trimmed too close to the skin are recommended for patients with PFB. Multiple-blade razors that cut the hair at skin level or just below the skin’s surface should be avoided.¹⁰ See TABLE 1 for additional shaving tips.

Chemical Depilatories: Chemical depilatories have been reported to produce fewer papules compared with manual razors, and these products provide another grooming alternative for patients who prefer a closer shave.¹¹ These products lyse the hair’s disulfide bonds and produce a soft, featherlike hair tip, which reduces the likelihood of extrafollicular penetration. In addition, because the hair tip is not below the surface of the skin, transfollicular penetration is less likely to occur.⁸ Most depilatory products use thioglycolate salts (i.e., calcium, potassium, and sodium thioglycolate) as an active ingredient. African American individuals and persons with coarse hair may require the use of stronger agents, such as sodium hydroxide, potassium hydroxide, strontium sulfide, or barium sulfide.^12,13 Chemical depilatories are available OTC and come in a variety of formulations (i.e., powders, creams, pastes, and lotions). Owing to the high alkalinity of depilatories, irritant contact dermatitis is the most common adverse effect (AE) associated with these products.¹⁴ Patients should be advised to read the product instructions carefully because inappropriate usage or frequent and prolonged exposure, especially with the stronger agents, could result in chemical burns.

Pharmacologic Treatment

Benzoyl Peroxide: Benzoyl peroxide has antibacterial effects against Propionibacterium acnes and also acts as a keratolytic and anti-inflammatory agent. It is commonly used alone or in combination with topical corticosteroids and topical retinoids as first-line therapy to reduce inflammatory and noninflammatory PFB lesions. Benzoyl peroxide may also be added to topical and oral antibiotic regimens to reduce the risk of bacterial resistance.¹⁵ Although they are available in a variety of concentrations and formulations, lower-strength (i.e., 2.5% and 5%) creams, lotions, and water-based gels are commonly applied once or twice daily to treat PFB. Frequently reported AEs for benzoyl peroxide include erythema, dry skin, and contact dermatitis. Patients should be informed that benzoyl peroxide may bleach the hair and clothing.

Corticosteroids: Skin irritation and inflammation characterize the symptoms associated with PFB, rendering topical corticosteroids a mainstay of treatment. Most anti-PFB regimens include a low- to mid-potency topical corticosteroid (i.e., betamethasone 0.05%-1% or hydrocortisone 0.5%-1%) that is applied one to three times daily. Occasionally, intralesional injections with triamcinolone acetonide (10 mg/mL) may be necessary to control severely inflamed papules or to manage hypertrophic scarring and keloid formation. Local irritation, redness, and new acne formation are associated with the use of topical corticosteroids, whereas injection-site pain, bruising, bleeding, and lipoatrophy may occur with intralesional triamcinolone acetonide injections.⁵

Topical Retinoids: The topical retinoids tazarotene 0.05% or 0.1% (Tazorac), tretinoin 0.02% or 0.1% (Retin-A), and adapalene 0.1% or 0.3% (Differin) may be particularly useful in treating PFB because they not only improve hyperkeratosis but also can help reduce transfollicular penetration by removing the thin layer of epidermis that prevents the hair from emerging from the follicle.¹ Topical retinoids are available in cream, gel, or liquid (tretinoin only) formulations and should be applied once daily in the evening or before bedtime. Local skin reactions (e.g., dryness, erythema, pruritus, scaling, hyper- or hypopigmentation, blistering, and stinging) are the most commonly reported AEs. Retinoid creams cause less drying than gels. Patients who experience AEs should be advised to consider switching to adapalene, which is usually better tolerated than other topical retinoids.¹⁶

Antibiotics: Although bacteria are not believed to be involved in the initial development of PFB, colonization of the normal flora may lead to increased inflammation and secondary infection.^8,17 Topical antibiotics may be used as initial therapy to treat PFB in patients who have very oily skin or those with acne vulgaris. Both topical clindamycin 1% (Cleocin T topical solution) and erythromycin 2% (Erygel) have anti-inflammatory actions and are effective for reducing bacterial colonization within the follicles and preventing secondary infection. The agent should be applied to the affected area twice daily. Topical antibiotics may cause local burning, itching, and dryness.

Oral antibiotics are usually reserved for severe cases of PFB or cases in which secondary infection and/or abscess formation is apparent.⁸ Depending on the severity of the condition, antibiotic therapy with tetracycline (250-500 mg twice daily), minocycline (50-100 mg twice daily), doxycycline (50-100 mg twice daily), or erythromycin (250-500 mg 2-4 times daily) may be necessary for several weeks to months. Potential AEs associated with these antibiotics include abdominal cramping, nausea, vomiting, diarrhea, and increased sensitivity to sunlight (with minocycline, tetracycline, and doxycycline).

Adjunctive Agents: Topical eflornithine hydrochloride cream 13.9% (Vaniqa) is indicated to reduce facial hair in women with hirsutism, but it also has been reported to decrease the number of inflammatory pustules in males with PFB.¹⁸ Eflornithine hydrochloride, which reduces hair growth by irreversibly inhibiting ornithine decarboxylase, is most effective as an anti-PFB agent when it is used in combination with other topical depilatories or in between laser treatments.¹ It should be applied to the affected area twice daily, at least 8 hours apart, and the patient should be instructed not to wash the treated areas for at least 4 hours. Reported AEs include minor skin irritation and new acne formation. Patients may also experience local burning and stinging if the cream is applied to broken skin.

Skin-lightening agents may be indicated for postinflammatory hyperpigmentation (PIH) associated with PFB. Hydroquinone, the most frequently used agent for the treatment of PIH, is thought to depigment the skin by inhibiting tyrosinase, which blocks the conversion of dihydroxyphenylalanine to melanin. It is available OTC at a concentration of 2%, but strengths up to 10% may be prescribed. Common AEs include irritation, burning, stinging, fissuring, and contact dermatitis.¹⁹ Other products frequently used to treat PIH include azelic acid, kojic acid, and retinoic acid.

Surgical Options

Chemical Peels: Superficial chemical peels that contain high concentrations of glycolic acid (20%-70%) or salicylic acid (20%-30%) may benefit some patients with PFB.^20,21 Both agents are effective exfoliants; however, their exact mechanism of action in the treatment of PFB is unclear. It is speculated that glycolic acid reduces the sulfhydryl bonds in the hair shaft, causing the hair to grow straighter and, in turn, reducing the potential for extrafollicular penetration.²² Salicylic acid exhibits anti-inflammatory properties and is also an effective keratolytic and comedolytic agent.²³ Both products are usually well tolerated, and local burning and stinging at the application site are the most commonly reported AEs.

Laser Therapy: The destruction or permanent removal of the hair follicle via laser therapy is regarded as the treatment modality that is closest to a PFB cure. A variety of different laser epilation systems are available; however, long-wavelength lasers (e.g., neodymium-doped yttrium aluminum garnet [Nd:YAG] and long-pulsed diode lasers) are safer and better suited for African Americans and patients with darker skin types.²⁴ In clinical trials, Nd:YAG lasers significantly reduced the number of papules and pustules in patients with types IV-VI skin.^25,26 The long-pulsed diode laser was reported to be effective for treating PFB in patients with darker skin types, but it was better tolerated in patients with type V skin than in those with type VI skin.²⁷ Patients should be informed that it can take several treatment sessions to achieve permanent hair removal and that possible AEs include erythema, crusting, and burns with scar formation.¹

Conclusion

PFB is a common inflammatory skin condition that usually occurs in the beard area in men of African ancestry as a result of shaving. Pharmacists can have a major impact on the management of PFB because patient education is essential for the prevention and successful management of this condition. In most patients, PFB can be successfully managed by altering grooming habits and using available topical and systemic treatment options. If results of other treatment modalities are unsatisfactory, hair-follicle removal via laser therapy is a viable option that could possibly result in the cure of PFB.

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