Pseudofolliculitis barbae



Pseudofolliculitis barbae


Gary J. Brauner


Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports


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Pseudofolliculitis barbae (PFB) is a chronic inflammatory disease of hair-bearing areas induced by shaving or plucking of curved hairs, with resultant transepithelial or transfollicular penetration by the sharpened hair remnant and a foreign body reaction. It is characterized clinically by papules, papulopustules, focal or diffuse postinflammatory hyperpigmentation, growth grooves, and rarely hypertrophic or keloidal scarring.



Management strategy


Because this process is induced by shaving its cure is simple: by not shaving or plucking at all and allowing the hairs to grow to beyond 1 cm in length, the disease will spontaneously involute. If a clean-shaven appearance is preferred or deemed necessary by occupational or social demands, management involves three elements:



Embedded hairs should be lifted, not plucked, just prior to shaving. A safety razor set on its ‘gentlest’ setting, or a pre-adjusted razor such as the PFB Bumpfighter™, should be used, but with the opposite hand kept off the face to prevent skin stretching. Shaving is performed in the direction of hair growth, not against it, again to prevent too-close shaving and transfollicular penetration. A long pre-soak with a hot wet facecloth will allow hairs to swell and lift; a shaving cream that lathers and holds well will keep those hairs saturated and elevated. Shaving must be performed daily; by 2 to 3 days of no shaving transepidermal re-entry penetration will occur. If morning shaving is routine, the affected areas should be gently buffed or brushed the evening before with a toothbrush, a rough dry washcloth, or a Buf Puf ™ to loosen hairs about to embed.


Hair clippers will cut hair closely but not so close as to allow transfollicular penetration. Because razor shaving is much closer, clippers should be used at least twice daily to avoid a permanent ‘5 o’clock shadow.’


Powder chemical depilatories are not practical. They are messy to use, hard to mix accurately, difficult to remove rapidly, and, because they are so irritating, cannot be used more than every 3 days, which already allows PFB to recur. Lotion depilatories are much easier to apply and remove and, being less irritant, can be used every 2 days to produce a satisfactory cosmetic appearance.


Antibiotics are not necessary topically because this is a sterile foreign body reaction not a pyoderma. Irritants such as retinoic acid or glycolic acid may enhance lifting of hairs and diminish hyperpigmentation.


Several longer-wavelength long pulsed lasers (alexandrite, 810 nm diode, and Nd:YAG) or intense pulse light (IPL) sources combined with epidermal protective chilling devices can be used to produce dramatic long-lasting remission, even in Fitzpatrick types IV, V, and VI patients, and represent a breakthrough treatment for recalcitrant disease. Caution must be employed in dosage selection based on the patient’s underlying skin color, since the hyperpigmented papules themselves may act as highly absorbing hotspots not anticipated by overall lighter skin color and may develop visible burns. Hyperpigmentation may involute without specific bleaching agents as the inflammation subsides when hairs disappear. Otherwise strategies employing techniques for both epidermal and tattoo-like dermal pigmentation need to be attempted.



Specific investigations






No investigations are necessary for usual cases of PFB. As it is induced by hair manipulation, i.e., shaving or plucking, it is not associated with other diseases. Differentiation of true bacterial folliculitis requiring systemic antibiotics must sometimes be considered. Rarely, yeast folliculitis may mimic PFB. Careful clinical inspection and possibly skin biopsy should be performed to rule out granulomatous disease such as sarcoidosis or dental sinusitis in the presence of apparently hypertrophic or keloidal scars. Rarely, cyclosporine therapy may induce a pseudofolliculitis-like condition. Recent French literature cites necrotic folliculitis-like lesions and pathergy as common cutaneous presentations of Behçet syndrome; this ‘pseudofolliculitis’ is not the PFB of ingrowing hairs.











An unusual Ala12Thr polymorphism in the 1A alpha-helical segment of the companion layer-specific keratin K6hf: evidence for a risk factor in the etiology of the common hair disorder pseudofolliculitis barbae.

Winter H, Schissel D, Parry D, Smith TA, Liovic M, Birgitte Lane E, et al. J Invest Dermatol 2004; 122: 652–7. Comment in: J Invest Dermatol 2004; 122: xi–xiii.


The authors identify a family with two curly-haired white males with PFB and one straight-haired non-PFB-afflicted female with an unusual dominantly inherited single-nucleotide polymorphism, which gives rise to a disruptive Ala12Thr substitution in the 1A α-helical segment of the companion layer-specific keratin K6hf of the hair follicle. In transfected cells this gene seems to be disruptive of filament assembly. A test group of 100 black people, 82% of whom had PFB, and 110 white people (a very high 18% of whom had PFB) showed this unusual gene in 9% of whites but only 36% of blacks (97% of whom had PFB).


The authors somehow conclude that this gene represents a significant genetic risk factor for PFB.

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Aug 7, 2016 | Posted by in Dermatology | Comments Off on Pseudofolliculitis barbae

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