Pseudofolliculitis barbae (PFB) is a common inflammatory reaction of the hair follicle, most often on the face as a result of shaving. Also known as “razor bumps” or “shaving bumps”, it can also occur on any site where hair is shaved or plucked, including the axilla, pubic area, and legs.
Folliculitis barbae presents similarly, but is due to infection. Folliculitis barbae and pseudofolliculitis barbae can coexist.
Who gets pseudofolliculitis barbae?
Although PFB can occur in men of all races, it predominantly affects men of African ancestry (approximately 45–80%). This is likely due to a greater prevalence of tightly curled, coarse hair in the African population. A study demonstrated that the presence of a single nucleotide substitution in the hair follicle companion layer-specific keratin (K6hf) is an additional risk factor. It can also affect women of all races, especially occurring in the groin.
It is associated with improper shaving technique and is more common with blade razor users compared to electric shavers.
What causes pseudofolliculitis barbae?
Razor bumps are thought to be caused by intrafollicular or transfollicular penetration of tight curly hair, often of coarse nature. They may also occur in skin folds or scar tissue, allowing straight hair to re-enter.
This often occurs due to close shaving, as cut hair results in a sharp pointed end and may re-enter by either:
Piercing the skin surface (transfollicular)
Retract beneath the skin surface and pierce the follicular epithelium (intrafollicular).
This subsequently leads to a foreign body inflammatory reaction. The injured follicles are highly susceptible to infection, causing folliculitis barbae.
What are the clinical features of pseudofolliculitis barbae?
An acne-like eruption presenting as ingrown hairs associated with flesh-coloured or red follicular papules.
Most often on the face and neck of men after shaving.
Under the jawline is typical, a site where the hair follicles grow in various directions.
PFB may also occur in any site where hair is shaved or plucked, including the axilla, pubic area, and legs.
May be itchy or tender.
Lesions may bleed when shaved.
May coexist with, and be aggravated by eczema/dermatitis.
Once healed, postinflammatory hyperpigmentation and scarring may occur.
How do clinical features vary in differing types of skin?
Pseudofolliculitis barbae is more common in those with darkly pigmented skin. It is also more likely to occur in those with curly and coarse hair.
What are the complications of pseudofolliculitis barbae?
•Folliculitis barbae
•Abscess
•Postinflammatory •hyperpigmentation
•Scarring including keloid scarring
How is pseudofolliculitis barbae diagnosed?
Pseudofolliculitis barbae is a clinical diagnosis. Dermoscopy may be used as an aid to visualise ingrown hairs and exclude differential diagnoses.
What is the differential diagnosis for pseudofolliculitis barbae?
•Folliculitis barbae
•Tinea barbae
•Acne vulgaris
•Folliculitis keloidalis (keloidalis nuchae)
•Cutaneous sarcoidosis
What is the treatment and prevention for pseudofolliculitis barbae?
The safest and most definitive cure is to discontinue shaving activity, thus patients should have the cause of PFB clearly explained to them. This may be unsuitable for many (eg, work, cultural, or personal reasons). If shaving is discontinued, it may take several weeks for the inflammatory response to cease (whilst hairs regrow).
General measures
•Ensure proper shaving technique or trialling different techniques to find which suits best. It may also be beneficial to:
•Shave in the direction of the follicle, not against it
•Do not stretch the skin
•Use short strokes
•Use sharp blades
•Avoid shaving in the same area twice (leave approx. 1 mm of stubble)
•Shave with the non-shaving hand behind the back (to reduce the temptation to make the skin taught, and thereby producing an extra close shave).
Trial switching from a blade razor to an electric shaver.
Reduce shaving activity e.g. only every other day.
•Consider alternative hair removal techniques eg, laser therapy.
•Ensure skin is well moisturised — preparations containing glycolic acid can exfoliate the skin surface and reduce the risk of new inflamed spots.
Specific measures
•A topical steroid cream and/or topical antimicrobials (e.g., clindamycin, erythromycin) can reduce mild inflammation and itching.
•Topical acne treatments such as benzoyl peroxide and tretinoin are used to suppress follicular hyperkeratosis.
•Oral antibiotics such as tetracyclines may reduce inflammation.
•10 minute compresses of warm water, saline, or burrows solution (aqueous solution of aluminum acetate) can help soothe the area and remove crusts.
•Chemical depilatories can help prevent PFB such as barium sulfide paste and calcium thioglycolate; these can be irritating.
Photodynamic therapy.
Laser epilation (Nd YAG).
Pharmahub is greatly educating. Keep it up.
THE 10 COMMANDMENTS PREVENTING OF INGROWN HAIRS by WIZKER:
1. THOU SHALT NOT USE DIRTY BLADES!
Using a blade that’s been used way too many times. Yes, this one may be obvious, but be sure to keep your used tools as clean as possible. Soap and rubbing alcohol will destroy bacteria. Pro Tip: even brand new blades need to be cleaned.
2. HONOR THY DELICATE SKIN!
Too many blades! If you are prone to ingrown hairs then you don’t need 3 or more blades. More blades equal more passes causing the hair to fall beneath the skin and become ingrown plus more blading the skin leads to micro cuts through which bacteria is more likely to enter and this leads to razor burn.
3. DO NOT TAKE PREP TIME IN VAIN!
You should be using a warm/hot water prep (3-5 mins). Then leave the shaving cream on for more than 2-3 minutes to really soften the hair. The hair stubble should literally fall away with little or no pressure at all. Pressing hard is the problem! Be gentle ya’ll.
4. THOU SHALT NOT GO AGAINST THE GRAIN!
Shaving against the grain (upwards) may get you a closer shave but doing so also increases ingrowns. Shave in the direction of hair growth…it’s usually downwards. Check by doing a face/ body inspection to see which way your hair grows.
5. THOU SHALT NOT PRESS!
Pressing too hard on the skin with the blade. A gliding, light touch is all you need. This is likely your biggest issue.
6. THOU SHALT NOT PASS, PASS, PASS!
Too many quick passes with the blade. One pass per hairy area – going 1-2 inches downward at a time – will prevent ingrown hairs. Always shave like you might cause damage, not like your mowing the front yard lawn.
7. THOU SHALT NOT COMMIT OVER SHAVING!
Shaving too many times. This rule is hard to follow, especially if you have to be beardless for your career…but if you are prone to ingrowns, try shaving with an electric clipper (the barber kind of clippers). The results are not super close but no one but you will know the difference. Ladies: try waxing, Nair, or an epilator provided your skin can handle these alternatives.
8. THOU SHALT NOT CLOG!
Use of skin/pore clogging creams or lotions keep hairs from growing up. After a shave, keep your skin bare; let the tiny army breath, and allow those newly shaved, really small, microscopic hairs to grow out just in time for the next shave. If your objective is smooth, bump-free skin following a shave or wax then, right after, your goal should be to allow the skin to heal first. Promote healing by proper shaving techniques followed by 70% rubbing alcohol (this kills any bacteria that may enter those micro cuts created from the shave). Using a dab of TendSkin prevents the onset of razor burn. Sure your skin will be a little dry at first but this is a temporary tradeoff. Give it a few hours and let the moisturizing commence!
9. KEEP THY SMOOTH SKIN FREE!
At least for the first day or two, try to avoid tight fitting clothing around the Adam’s apple (neck) and/or below the waistline region. Newly shaved hair follicles need room to raise up.
10. REMEMBER TO EXFOLIATE!
Whether you shave, sugar, wax or epilate, not enough exfoliation to remove excess layers of skin can lead to ingrown hairs. There are two types: chemical exfoliation (AHA, BHAs) and physical exfoliation (beads, coffee scrubs, gloves, brushes). Use an ingrown hair brush for razor bumps as directed. Make sure it’s a brush that has gentle bristles designed to tease newly shaved hairs away from entering the skin before they can become ingrown. If you have sensitive skin, then go with the soft and firm bristles. Try a Wizker brush and you’ll prevent razor bumps and ingrown hairs permanently!