Dermatologic Conditions in Men of African Ancestry

Marcelyn K Coley; Andrew F Alexis


Expert Rev Dermatol. 2009;4(6):595 

In This Article

Pseudofolliculitis Barbae

Pseudofolliculitis barbae is a common inflammatory follicular disorder characterized by papules and pustules localized to the beard and neck, and is seen most frequently in men of color. It is readily referred to as 'ingrown hairs' or 'razor bumps' by patients and the lay public. Generally associated with shaving, PFB may occur in any hair-bearing area.


Pseudofolliculitis barbae primarily affects men with curly, coarse hair. The prevalence has been reported to be between 45 and 83% in African–American men and is a leading concern among black US Army recruits.[1–3] A survey conducted at the Skin of Color Center involving 71 patients with PFB (41 females and 30 males) showed an average age of onset of 22 years.[4]


Pseudofolliculitis barbae is a chronic foreign-body reaction to an ingrown hair shaft. It is thought that the characteristics of the hair seen in individuals of African descent – a curved hair follicle and curly shaft – predispose cut hair to re-enter the dermis leading to the subsequent inflammatory reaction. Two mechanisms of hair shaft re-entry have been described: extrafollicular and transfollicular penetration. In extrafollicular penetration, the sharp edge of the shaved hair follows its natural curvature to the skin surface and re-penetrates the epidermis in a retrograde fashion (Figure 1). Transfollicular penetration refers to piercing of the follicular wall by the recently cut hair shaft, which then enters the dermis without ever exiting the epidermis.[1,2,4] Pulling of the skin tautly while shaving increases the risk of transfollicular penetration by allowing newly cut hair to retract beneath the skin's surface. Transfollicular penetration may also be responsible for ingrown hair seen with plucking or waxing, which can leave hair fragments within the skin.[2,4] In both types of re-entry, the hair shaft penetrates the dermis, triggering a foreign-body inflammatory response that results in the formation of papules and pustules.[1,2] A single nucleotide polymorphism, identified by Winter and colleagues, appears to impart partial genetic risk for the development of PFB. This is believed to occur via a disruptive Ala12Thr substitution, in the 1A α-helical segment of the companion layer-specific keratin K6hf.[5]

Figure 1.

Pathogenesis of pseudofolliculitis. Extrafollicular re-entry.
Redrawn with permission from [20].


Clinical Features

While follicular and perifollicular papules and pustules in the beard area are the clinical hallmarks of PFB, postinflammatory hyperpigmentation (PIH) is a commonly associated feature (reported in up to 90%).[4] The most commonly affected area is the bearded region of the face, including the anterior neckline, submental and mandibular areas, chin and cheeks (Figure 2). Hypertrophic scars or keloids are also potential sequelae, usually seen in severe cases. Embedded hair is often seen within papules. This hair will spontaneously release through a loop mechanism after growing approximately 1 cm in length.[6] Grooved, linear, depressed patterns in the skin may also be present due to parallel hair growth.[4] Some patients may complain of pain or itching. Except in cases of secondary infection, cultures of pustules are usually sterile or contain normal flora.

Figure 2.

Pseudofolliculitis barbae.

The presence of PFB lesions may be very distressing to patients, and can be associated with considerable anxiety regarding their appearance. Historically, PFB has contributed to racial tension among African–American men in the US Armed Forces due to the military grooming code requirement for a clean-shaven face. For many of these men, in order to avoid facing discharge, compliance with the military code meant suffering with PFB.[3,4]


Prevention Strauss and Kligman noted that allowing the beard to grow for approximately 1 month resulted in spontaneous resolution of most PFB papules.[6] However, beard growth may not always be possible. Occupational mandates on a clean-shaven appearance or personal preference may be limiting factors. In such cases, when shaving avoidance is not an option, patient education and counseling about proper shaving techniques and alternative hair removal options become necessary to control and reduce flares (Box 1).

Most men can control the condition by maintaining an optimal beard length of 0.5–1 mm.[2–4,7] Electric clippers are often recommended for this purpose as they can be set to cut hair to the desired length.[2] Traditionally, most authorities have suggested the use of a single blade razor due to concerns about facilitating transfollicular penetration with closer-shaving multi-edged razors..[4] A single blade razor such as the Bump Fighter™ (American Safety Razor Company, VA, USA) has been recommended, as it includes a polymer coating and a foil guard that keeps the blade edge slightly off the skin to prevent hair from being trimmed too short.[1,2,7,8] This razor has been shown to significantly reduce the number of PFB lesions in one study.[8] However, a recent study conducted by Gillette® (Proctor and Gamble, OH, USA), found no increase in the number of PFB lesions and no worsening of PFB global severity scores in men who shaved daily with a five-blade razor (Fusion Power®) for 8 weeks.[202] Randomized, blinded clinical trials comparing the use of multi- and single-edged razors, different shaving techniques and shaving frequencies are needed to elucidate optimal shaving recommendations for PFB.

Medical Management A combination of therapies is often used to treat PFB, with frequent use of topical retinoids, low-potency corticosteroids and topical antibiotics (Box 2). Topical retinoids (i.e., topical tazarotene, tretinoin or adapalene nightly) help to alleviate the hyperkeratosis associated with repeated nicking of the follicular epithelium,[4] as well as PIH. Low- to mid-potency topical corticosteroids (e.g., desonide cream) applied in the morning can be used in place of commercial aftershave products.[1,7] A benzoyl peroxide wash may be added prior to shaving. Benzoyl peroxide and other antimicrobials (e.g., clindamycin, erythromycin) reduce the colonization of bacteria that can aggravate inflammation and lead to secondary infection;[4] topical antibiotics also confer anti-inflammatory effects.[9] PFB-associated PIH may be effectively treated with bleaching agents such as hydroquinone 4%, azeleic acid 15 or 20% and kojic acid. Monthly intralesional steroids are effective in addressing secondary hypertrophic or keloidal scars[7] or severely inflamed papules.

Chemical Depilatories Several hair-removal options are available for men burdened with this condition. Chemical depilatories have been used as an alternative to shaving for many years. These substances (barium sulfide or calcium thioglycolate) exist in powder, paste, cream and lotion forms, and work by weakening the disulfide bonds in keratin so that hair is easily removed from the skin's surface with a blunt instrument (i.e., wooden spatula). The resultant blunt hair tip makes extrafollicular and transfollicular penetration less likely.[4] These chemicals have potential to cause irritant or allergic reactions resulting in PIH if exposure is prolonged. A test patch is recommended to determine irritation potential prior to treatment.[2]

Eflornithine hydrochloride cream, 13.9% (Vaniqa®, Skin Medica, CA, USA) is US FDA-approved for the treatment of unwanted facial hair in women. It irreversibly inhibits skin ornithine decarboxylase, an enzyme in hair cell division, which results in a decreased hair growth rate in the area applied. Although not indicated for use in PFB, it has been used for the purpose of decreasing hair growth in men with PFB.[1,2,7] Of note, the benefit of therapy is only maintained with its continued use. Eflornithine is not a depilatory, and therefore other hair-removal methods should be used concurrently. These considerations should be discussed with patients to avoid unrealistic expectations.

Epilation Electrolysis is a form of permanent hair removal that can be considered for limited areas. However, it has the potential to be painful and costly. Moreover, electrolysis is often unsuccessful in individuals of African descent due to difficulty in ablating the curved and often distorted hair follicle secondary to previous manipulation.[10] A blend method of electrolysis using galvanic and thermolysis currents has been effective.[10] Nonetheless, electrolysis may actually exacerbate PFB, perhaps promoting transfollicular penetration, and therefore is generally not recommended.

Surgical Approaches The most recent advance in the management of PFB is laser-assisted hair removal with the development of lasers that have been proven to be effective and safe for darker skin types; these include the diode (800–810 nm)[11–13] and the Nd:YAG (1064 nm).[11,14,15] By reducing the amount of hair in affected areas, the risk of developing PFB is decreased accordingly. Smith and colleagues found that using a very long pulsed 810-nm diode laser improved PFB in type V skin.[13] Ross et al. reported the use of Nd:YAG 1064 nm coupled with contact cooling as an effective treatment option for PFB in skin types IV–VI, documenting significant reduction in hair and subsequent papule formation.[14] Examination of biopsies after treatment revealed evidence of hair bulb damage with preservation of the epidermis. This supports the concept that longer wavelengths offer better penetration and, therefore, less thermal damage to the epidermis,[14] which may lead to severe complications in skin of color. Weaver and Sagaral also reported effective use of the long-pulse 1064-nm Nd:YAG laser in patients with skin types V and VI with active PFB; observing mean papule/pustule percentage reduction of nearly three-times that of the control after two treatments.[15] Minimal side effects were observed including transient hyperpigmentation, transient hypopigmentation, mild erythema and itching. In a recent study, Schulze et al. noted significant improvement in all parameters including papule count (91.2% reduction) after five weekly treatments with the 1064-nm Nd:YAG laser using a low fluence (12 J/cm2) in skin types IV–VI.[16] Prior studies have used fluence ranges from 24 to 70 J/cm2. The authors proposed a possible theory of laser-mediated anagen effluvium secondary to repetitive sublethal thermal injury as being responsible for the successful effects.[16]

Chemical peels Superficial chemical peels are effective and safe adjuncts to therapy for PFB. In addition to its exfoliating effect, it has been proposed that the reducing properties of glycolic acid may reduce sulfhydryl bonds in the hair shaft, resulting in straighter hair growth, and thereby may potentially reduce the chance for re-entry of the hair shaft into the epidermis.[17] Salicylic acid peels offer exfoliation and lightening in cases complicated by PIH.[7] Reduced numbers of PFB lesions have been observed with both glycolic acid and salicylic acid peels.[1,17–19]