Pseudofolliculitis Barbae: A Review of Current Treatment Options

March 2019 | Volume 18 | Issue 3 | Original Article | 246 | Copyright © 2019

Dillon Nussbaum BSc and Adam Friedman MD FAAD

George Washington University Medical Faculty Associates, Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC

Abstract

The purpose of this review is to discuss the disease process and wide variety of treatment options for psuedofolliculitis barbae (PFB), or razor bumps. PFB is caused by hair follicles penetrating the skin and causing an inflammatory response. PFB can occur to anyone who shaves, and is more likely in those with curly hair. PFB can cause significant hyperpigmentation and scarring, more noticeable in darker skin types. PFB can be treated with a variety of topical, systemic, or light/laser therapies. Minimal progress has been made in treating PFB in recent years, partially due to the success of well-established current treatments discussed in this review. The most effective treatments involve a multifaceted approach including behavioral changes in shaving habits as well as the use of topical therapies.

J Drugs Dermatol. 2019;18(3):246-250.

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INTRODUCTION

Pseudofolliculitis barbae (PFB) is a chronic inflammatory condition of hair bearing areas characterized by “razor bumps” or inflammatory papules or pustules arising around affected follicles. PFB is a result of both genetic and environmental variables in that the genetically determined curvature of hairs, combined with an individual’s shaving practices can induce PFB. If curly enough, or grown at a tangential angle, recently shaved hairs can curve back into and pierce the perifollicular epidermis leading to an immune mediated granulomatous foreign body reaction. PFB is more common in men of African descent but is also observed in Hispanic and middle eastern men as well as other populations where curly hair is common. PFB is most common in men but can happen to women in any hair bearing area that is shaved, most commonly the axilla and groin as well as the face in women with facial hirsutism.Treatment of PFB includes treating the symptoms, sequelae, and most importantly, the root cause of the chronic condition. As with any inflammatory cutaneous condition, PFB can lead to post inflammatory pigment alteration and permanent scarring. Furthermore, the inflammatory cascade in PFB can be worsened by bacterial flora that penetrate through the defects in the skin barrier caused by follicular reentry. Treatment is aimed at reducing the inflammation that can thereby reduce the secondary pigment alteration and scarring. Many different modalities can be useful for the various symptoms of PFB including corticosteroids, skin lighteners, retinoids, antibiotics, keratolytics, depilatories, and laser therapy. Because of the chronicity of the condition, long term treatment should be aimed at avoiding continuous follicular reentry into the perifollicular epidermis. We will explore further the disease process of PFB so that each treatment option can be understood based on the mediating properties of each modality.Epidemiology and Pathogenesis PFB commonly affects men due to constant shaving of facial hair but it can also occur in women wherever hairs are shaved.1 PFB affects people with naturally curly hair more so than straighter haired individuals. Men of African ancestry tend to have curlier hair and one study found that the incidence of PFB among African American men to be 45% to 83%. PFB also commonly occurs in those of Hispanic and middle eastern descent but can ultimately happen to anyone who constantly shaves their hair, especially if that hair is curly.2 PFB is commonly seen in the military and police forces where strict facial shaving habits are required and increase the potential for PFB to occur in those who are predisposed. Waivers exist for patients in the military and police officers who may need to sustain facial hair due to a medical diagnosis like PFB and should be utilized more often.3 Genetics determine the natural curvature of hair follicles and shaving practices determine the microscopic environment of the perifollicular cutaneous topography. In affected individuals, if hair follicles are cut too short, or if they grow at an angle towards the surrounding skin, follicles can penetrate the epidermis surrounding the follicular ostea from which they arise. One study identified a specific Ala12Thr substitution mutation in a hair follicle specific keratin 75 (formerly K6hf) gene that was found to be a commonality in 36% of PFB cases versus 9% in controls.4 Another study looked at the incidence of PFB in men

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