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Pseudofolliculitis of the Beard Treatment & Management

  • Author: Thomas G Greidanus, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Feb 10, 2016
 

Medical Care

Chemical depilatories

Chemical depilatories work by breaking the disulfide bonds in hair, which results in the hair being broken off bluntly at the follicular opening.[6]

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.

Topical medications

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.[7, 8]

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).[9]

Mild topical corticosteroid creams reduce inflammation of papular lesions.[7]

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.[10]

Antibiotics

For severe cases of pseudofolliculitis barbae with pustules and abscess formation, topical and oral antibiotics may be indicated.[11, 12]

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.

Special considerations

Pseudofolliculitis barbae is of particular concern in persons in the military. Enforcement of a clean-shaven face in those with this condition can cause scarring, hyperpigmentation, secondary infection, and keloid formation. The lack of understanding of this disease has created tension and hostility between soldiers and their chain of command. Proper education on shaving methods and treatment of pseudofolliculitis barbae, including judicious breaks from shaving (no shaving profiles), is essential.[13, 14, 15]

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Surgical Care

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.[16, 17, 18, 19]

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.[20] 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.[21]

Reportedly, excellent results can be obtained with the use of an 800-nm diode laser technique with low power and high pulse duration (5-15 J/cm2, 2 Hz, 100–400 ms), especially in darker-skinned individuals.[22]

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Diet

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

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Contributor Information and Disclosures
Author

Thomas G Greidanus, MD Emergency Physician, Parkview Medical Center

Thomas G Greidanus, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Received ownership interest from Incendant Inc. for other.

Coauthor(s)

Beth Honl, MD Dermatology Associates, PC; Private Practice

Beth Honl, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Associate Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Jaggi Rao, MD, FRCPC Clinical Professor of Medicine, Division of Dermatology and Cutaneous Sciences, Director of Dermatology Residency Program, University of Alberta Faculty of Medicine and Dentistry

Jaggi Rao, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, Canadian Medical Association, Pacific Dermatologic Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association, Canadian Dermatology Association

Disclosure: Nothing to disclose.

References
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  2. Quarles FN, Brody H, Johnson BA, et al. Pseudofolliculitis barbae. Dermatol Ther. 2007 May-Jun. 20(3):133-6. [Medline].

  3. Kindred C, Oresajo CO, Yatskayer M, Halder RM. Comparative evaluation of men's depilatory composition versus razor in black men. Cutis. 2011 Aug. 88(2):98-103. [Medline].

  4. Garcia-Zuazaga J. Pseudofolliculitis barbae: review and update on new treatment modalities. Mil Med. 2003 Jul. 168(7):561-4. [Medline].

  5. Chuh A, Zawar V. Epiluminescence dermatoscopy enhanced patient compliance and achieved treatment success in pseudofolliculitis barbae. Australas J Dermatol. 2006 Feb. 47(1):60-2. [Medline].

  6. Olsen EA. Methods of hair removal. J Am Acad Dermatol. 1999 Feb. 40(2 Pt 1):143-55; quiz 156-7. [Medline].

  7. Childs ND. Tretinoin, hydrocortisone cream controls PFB. Skin and Allergy News. 1999. 30(5):20.

  8. Kligman AM, Mills OH Jr. Pseudofolliculitis of the beard and topically applied tretinoin. Arch Dermatol. 1973 Apr. 107(4):551-2. [Medline].

  9. Taylor S. Open-Label Case Study on Triple-Combination Cream in Patients with Pseudofolliculitis Barbae. J Am Acad Dermatol. 2005. 52:P169.

  10. Callender V, Young CM. Combination Laser and Eflornithine HCL 13.9% Cream: A First-line Therapy for Fitzpatrick Type IV-VI Patients With Excessive Facial Hair. J Am Acad Dermatol. Mar 2005. 52(3) suppl:P209.

  11. Brown LA Jr. Pathogenesis and treatment of pseudofolliculitis barbae. Cutis. 1983 Oct. 32(4):373-5. [Medline].

  12. Leyden JJ. Topical treatment for the inflamed lesion in acne, rosacea, and pseudofolliculitis barbae. Cutis. 2004 Jun. 73(6 Suppl):4-5. [Medline].

  13. Alexander AM, Delph WI. Pseudofolliculitis barbae in the military. A medical, administrative and social problem. J Natl Med Assoc. 1974 Nov. 66(6):459-64, 479. [Medline].

  14. Brauner GJ, Flandermeyer KL. Pseudofolliculitis barbae. Medical consequences of interracial friction in the US Army. Cutis. 1979 Jan. 23(1):61-6. [Medline].

  15. Coquilla BH, Lewis CW. Management of pseudofolliculitis barbae. Mil Med. 1995 May. 160(5):263-9. [Medline].

  16. Bridgeman-Shah S. The medical and surgical therapy of pseudofolliculitis barbae. Dermatol Ther. 2004. 17(2):158-63. [Medline].

  17. Kauvar AN. Treatment of pseudofolliculitis with a pulsed infrared laser. Arch Dermatol. 2000 Nov. 136(11):1343-6. [Medline].

  18. Perry PK, Cook-Bolden FE, Rahman Z, Jones E, Taylor SC. Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends. J Am Acad Dermatol. 2002 Feb. 46(2 Suppl Understanding):S113-9. [Medline].

  19. Robins P, Battle EF Jr, Alexis AF, Cook-Bolden F, Alqubaisy Y, McLeod MP, et al. Unique laser techniques in patients with skin of color. J Drugs Dermatol. 2011 Dec 1. 10(12):4-26. [Medline].

  20. Schulze R, Meehan KJ, Lopez A, et al. Low-fluence 1,064-nm laser hair reduction for pseudofolliculitis barbae in skin types IV, V, and VI. Dermatol Surg. 2009 Jan. 35(1):98-107. [Medline].

  21. Ross EV, Cooke LM, Timko AL, Overstreet KA, Graham BS, Barnette DJ. Treatment of pseudofolliculitis barbae in skin types IV, V, and VI with a long-pulsed neodymium:yttrium aluminum garnet laser. J Am Acad Dermatol. 2002 Aug. 47(2):263-70. [Medline].

  22. Emer JJ. Best practices and evidenced-based use of the 800 nm diode laser for the treatment of pseudofolliculitis barbae in skin of color. J Drugs Dermatol. 2011 Dec. 10(12 Suppl):s20-2. [Medline].

  23. Alexander AM. Evaluation of a foil-guarded shaver in the management of pseudofolliculitis barbae. Cutis. 1981 May. 27(5):534-7, 540-2. [Medline].

 
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Pseudofolliculitis barbae on the neck of a black man.
 
 
 
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