Understanding Skin of Color
Defining pseudofolliculitis barbae in 2001: A review of the literature and current trends,☆☆,

https://doi.org/10.1067/mjd.2002.120789Get rights and content

Abstract

Pseudofolliculitis barbae (PFB) is a chronic inflammatory and potentially disfiguring condition most often seen in men and women of African American and Hispanic origin who have tightly curled hair and who shave or tweeze hairs frequently. The etiology is multifactorial. The shape of the hair follicle, hair cuticle, and the direction of hair growth each play a role in the inflammatory response once the hair is shaven or plucked and left to grow. This reaction often produces painful, pruritic, and sometimes hyperpigmented papules in the beard distribution. The result is an unappealing cosmetic appearance, often with emotionally distressing consequences for affected individuals. The diagnosis is made clinically. Currently, prevention and early intervention are the mainstays of therapy. Many treatment options are available; however, none has been completely curative. In this review, the history, incidence, pathogenesis, clinical manifestations, dermatopathology, prevention, and treatment of PFB, including the most current surgical options, will be discussed. In addition, new data on patients with PFB from the Skin of Color Center will be presented. (J Am Acad Dermatol 2002;46:S113-9.)

Section snippets

Epidemiology

The largest prevalence study to date, commissioned by the US Army, included 234 subjects and found a prevalence rate of 83% among black recruits. Numerous other articles have been written and have indicated a prevalence rate of 45% to 83%.4, 5 PFB is among the most common skin complaints of black patients.

PFB occurs in postpubertal males and females, with males ages 14 to 25 most often affected. Women are usually affected during the perimenopausal period because of changes in hormone levels

Etiology and pathogenesis

The structure of the hair and direction of hair growth in affected individuals play a major role in the initiation of events that lead to clinical evidence of pseudofolliculitis. There are 4 gross hair types: straight, wavy, helical, and spiral.6 Helical hair forms coils of constant diameter, whereas spiral hair forms coils that diminish in diameter outward. Black patients typically have helical or spiral-shaped hair shafts. These types of hair shafts have a more flattened or elliptical shape,

Clinical manifestations

The diagnosis of PFB is made on clinical grounds, based on the location and type of lesions. Papules and pustules that appear in the beard distribution are the most common presentation. The anterior neckline, mandibular areas, cheeks, and chin are the most commonly involved sites. The typical lesion site for women in our survey was the chin, whereas the neck was the most common site for men (Table I).

. Sites of PFB lesions among males and females with PFB presenting at the Skin of Color Center

Differential diagnosis

The differential diagnosis of PFB includes true folliculitis (inflammation of the follicle with evidence of primary infection), acne vulgaris, tinea barbae, impetigo, and sarcoidal papules.10, 16, 17, 19 Traumatic folliculitis (inflammation of the follicle without evidence of infection or follicular penetration) occurs as a result of shaving too closely and clinically appears as erythematous excoriations and small pink follicular papules. This condition resolves within 1 to 2 days after shaving

Classification

Dunn reported a grading system to classify PFB based on the number and severity of lesions10 (Table II).

. Grading system for PFB

Table available in print only
This system has been used to evaluate treatment success by documenting the number and distribution of papules and pustules at each visit.

Dermatopathology

The dermatopathologic picture seen in PFB is a consequence of penetration of the skin by the free end of the sharpened hair edge. The result is an invagination of the epidermis accompanied by recruitment of neutrophils and, often, an intraepidermal microabscess formation. The level of depth depends on how deeply the hair penetrates. As the hair enters the dermis, a more severe inflammatory reaction develops with downgrowth of the epidermis in an attempt to ensheath the hair. This is accompanied

Diagnosis

Initially, a thorough hair removal history and physical examination should be performed on a patient with PFB. Physical examination should assess the severity and current clinical status of PFB. In our survey, the majority of patients (57.7%) had not been previously treated by a physician, with 53.5% reporting that their condition was chronic or flaring at the time they visited the Skin of Color Center.

Once patients are seen, particular attention should be given to methods of hair removal,

Prevention

Given the pathogenesis of this disorder, it is understandable that the mainstay of therapy has involved preventive practices: primarily, the discontinuation of shaving or other forms of hair removal (electrolysis, tweezing, depilatory use, and waxing). Once thought to be a complete cure, approximately 10% to 20% of affected individuals continue to have inflammatory lesions after cessation of shaving and cannot wait the 2 to 6 weeks needed for complete cure. In the past, guidelines for obtaining

Adjunctive therapy to beard hair removal

A variety of topical agents may help decrease irritation after hair removal and are useful additions in the management of PFB. Neutral pH or more acidic emollients such as hydrocortisone cream (0.5% to 1%), 10% urea cream, and lactic acid may be helpful.

Kligman and Mills24 suggested that hyperkeratosis plays a small role in the pathogenesis of PFB. Topical retinoids (0.5% tretinoin, adapalene) in the cream, gel, or solution forms are beneficial in reducing the hyperkeratosis that often results

Electrolysis and surgical management

Other hair removal techniques, such as electrolysis and surgical (subcutaneous) depilation, have been used. Despite being used for many years, electrolysis of beard hairs is generally not recommended as it tends to be expensive, impractical, painful, and often unsuccessful. Additionally, PFB can result from electrolysis. The needle used in electrolysis may not reach the hair bulbs of the curved follicle and may induce a transfollicular-type penetration, thereby exacerbating PFB. Electrolysis

Conclusion

PFB is a chronic inflammatory condition that has psychosocial implications for the women and men it affects. Several treatment modalities exist, but none have provided a complete cure without substantial risk. Because the main inciting factors are the direction of hair growth and hair texture, the most promising treatment methods are those that optimize hair removal while protecting overlying skin. At present, laser hair removal using longer wavelengths and pulse durations is the most

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    This article is part of a supplement supported by Galderma Laboratories.

    ☆☆

    Disclosures: Drs Taylor and Cook-Bolden are clinical investigators for Allergan, Galderma, and Hill. Dr Taylor is a member of the Advisory Board for Galderma, Medicis, Proctor and Gamble, and Roche, and is a speaker for Allergan, Galderma, Medicis, Novartis, and Roche. Dr Cook-Bolden is a member of the Advisory Board for Galderma and Connetics, and is a speaker for Galderma, Dermik, and Roche. Drs Perry, Rahman, and Jones attest that they have no conflicts of interest to disclose.

    Reprint requests: Fran E. Cook-Bolden, MD, Department of Dermatology, St. Luke's-Roosevelt Hospital Center, 1090 Amsterdam Avenue, Suite 11D, New York, NY 10025.

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