Journal of the American Academy of Dermatology
Understanding Skin of ColorDefining pseudofolliculitis barbae in 2001: A review of the literature and current trends☆,☆☆,★
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).
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).
Table available in print only
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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2018, BurnsCitation Excerpt :In types VI–VIII hair, follicles are frequently paired [60], which can lead to tufting. These curled hair follicles more frequently exits the epidermis at an oblique angle relative to the skin [61] and the hair are more prone to form “ingrown hairs”, which can become infected and lead to folliculitis. It may also be the consequence of incorrect epithelialization, caused by over granulation due to deep harvesting of the SSG and subsequent entrapment of the hair in the granulation tissue.
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This article is part of a supplement supported by Galderma Laboratories.
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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.
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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.