Pseudofolliculitis of the Beard Treatment & Management

• Chemical depilatories work by breaking the disulfide bonds in hair, which results in the hair being broken off bluntly at the follicular opening.^[5]

  • Barium sulfide powder depilatories of about 2% strength can be made into a paste with water and applied to the beard area. This paste is removed after 3-5 minutes.
  • Calcium thioglycolate preparations come as powder, lotions, creams, and pastes. The mercaptan odor is often masked with fragrance. In rare cases, this fragrance can cause an allergic reaction. Calcium thioglycolate preparations take longer to work and are left on 10-15 minutes; chemical burns result if left on too long.
  • Chemical depilatories should not be used every day because they cause skin irritation. Every second or third day is an acceptable regimen. Irritation can be countered by using hydrocortisone cream. A lower pH or concentration, or a different brand, may also prove less irritating. Several products are available; therefore, trying a different product is encouraged if one depilatory proves to be unacceptable.
• Topically applied tretinoin (Retin-A) has shown promise for some patients. When used nightly, it alleviates hyperkeratosis. It may remove the thin covering of epidermis that the hair becomes embedded in upon emerging from the follicle.^{[6, 7]}
• Topical combination cream (tretinoin 0.05%, fluocinolone acetonide 0.01%, and hydroquinone 4%) (Triluma) has been shown to provide some benefit by targeting the hyperkeratosis (tretinoin), inflammation (fluocinolone), and postinflammatory hyperpigmentation (hydroquinone).^[8]
• Mild topical corticosteroid creams reduce inflammation of papular lesions.^[6]
• For severe cases of pseudofolliculitis barbae with pustules and abscess formation, topical and oral antibiotics may be indicated.^{[9, 10]}

  • Topical antibiotics may successfully reduce skin bacteria and treat secondary infection. These topicals include erythromycin, clindamycin, and combination clindamycin/benzoyl peroxide (Benzaclin, Duac) and erythromycin/benzoyl peroxide (Benzamycin) agents. Applying one of these agents once or twice per day is effective. Benzoyl peroxide applied topically once a day is also effective in reducing bacterial populations. It should be used sparingly and may be irritating to sensitive skin. It is a good first-line topical agent for persons with oily skin. Benzamycin is a combination of erythromycin and benzoyl peroxide. A once daily application has the benefits of both agents.
  • If pustules or abscess formation is evident, an oral antibiotic is indicated. Tetracycline is a common choice for a systemic antibiotic. Similar to a standard acne regimen, a dose of 500 mg twice a day used initially for 1-3 months is often effective.
• Topical eflornithine HCL 13.9% cream (Vaniqa) has been used for excessive facial hair and in patients with pseudofolliculitis barbae. It is also used as a combination with laser therapy for hirsute women and pseudofolliculitis barbae patients. It decreases the rate of hair growth. In addition, the treated hair may become finer and lighter.^[11]
• Dermoscopy has been used to demonstrate the pathophysiology and improve compliance.^[12]

• Newer hair removal lasers may have a role in the treatment of pseudofolliculitis barbae. The problem with most laser and high-intensity light source hair removal modalities is that the natural skin pigment may be damaged by the laser because melanin in the hair shaft is the target chromophore. Devices being studied at this time may avoid this depigmenting complication. Diode laser treatments have been proven safe and effective in patients with skin phototypes I-IV.^{[13, 14, 15, 16]}
• The use of long-pulsed Nd:Yag laser in the treatment of pseudofolliculitis barbae demonstrated a decrease in papule formation, miniaturization, and reduction of hair counts in skin types IV, V and VI.^[17] Most subjects had a return of normal hair growth after 6 months; however, 2 of 10 individuals had areas of permanent hair loss after 12-month follow-up. Adverse effects of long-standing hypopigmentation in this study were isolated, signifying that this particular laser is an encouraging modality of therapy.^[18]

No dietary therapies for pseudofolliculitis barbae have proven effective, and no dietary triggers of the condition have been identified.