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Case Note

Case Note: Papulopustular Eruption on the Face

History

A 19-year-old healthy male, with no significant past medical history, presents for evaluation of long-standing facial eruption, with irritation believed to be due to shaving.

Initial evaluation

  • Healthy-appearing male
  • No significant past medical history
  • Presents for management of long-standing facial eruption
    • Extensive follicular-based papules and pustules in a beard distribution, numerous ingrown hairs and macules of post-inflammatory hyperpigmentation noted
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    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of pseudofolliculitis barbae (PFB) is rendered

Initial Treatment

  • Extensive counseling regarding the goals of the therapeutic strategy
  • Recommendations:
    • New strategies for shaving
    • Hydrocortisone 1% lotion applied every other day, with tretinoin 0.025% cream on alternating days
  • Follow-up in 6 weeks 

Follow-up evaluation strategy

Ongoing follow-up evaluation:

  • Follow-up at 2- to 3-month intervals for 6 months is continued
  • Condition is improving overall, though still persistent, and the post-inflammatory pigmentary changes are also resolving
  • The patient starts a regimen of laser hair removal to the affected areas
    • Symptoms resolve

Further recommendations:

  • Improved shaving technique:
    • Razor shaving: Using a single-bladed, adjustable or foil-guarded razor is the most effective method for patients with mild-to-moderate PFB. Correct technique for razor shaving includes dislodging ingrown hairs, soaking the beard with shaving cream for several minutes, shaving with the grain, avoiding skin stretching, shaving each area once and shaving every day to every third day for optimal hair length (hair just out of follicle and not ingrowing)
    • Depilatory shaving: Using barium sulfide or calcium thiogylcolate, depilatory shaving is timely, irritating (restricting use to around twice weekly) and has an unpleasant smell; however, it is more effective in patients with moderate-to-severe condition. Correct technique for depilatory shaving includes applying the powder/cool water mix to sections of the beard at a time, removal with a moist spatula as hairs dissolve (after approximately 2-3 minutes) and wash area thoroughly with cool water/soap, repeat technique per beard area and apply hydrocortisone 1% post-shave and twice daily
    • Clipper shaving: Most PFB patients will be able to trim their beard with triple-zero barber clippers with good results (~1/16-inch stubble). Some patients with mild-to-moderate condition may be able to shave closer, after clipping, with a rotary triple-headed razor. A pre-shave is recommended when using clippers or rotary shavers

General discussion

PFB, or razor bumps, is a condition which commonly affects black individuals, though it may present in hair-bearing areas of skin in persons of all races. PFB may be the most common dermatologic condition of African-Americans, with a prevalence as high as 45-83%. The pathophysiology is largely unknown. This condition likely stems from inward growth of tightly curled hair within the hair follicle, resulting in abscess formation or a foreign-body giant cell reaction in a follicle-based distribution. It is often exacerbated by shaving and resolves when the inciting form of hair removal is stopped.

There are some basic factors that make management challenging: No method of hair removal, especially shaving, works for all patients, and, with time, many patients learn the best hair removal technique for them but often only after numerous unsuccessful attempts. Also, many individuals with PFB cannot be continuously 'clean' shaven, which may result in social isolation or interfere with certain forms of employment (which do not allow for facial hair).

Severity of the condition dictates therapeutic options. Laser epilation offers an important therapeutic option for individuals with PFB, when available. Addressing secondary pigmentary alteration and/or keloid formation may also be an important aspect of the therapeutic strategy.

Treatment:

  • Patient education is a cornerstone of management and must be detailed, honest and repeated on subsequent visits. Management of the condition, rather than cure, may be the most realistic therapeutic strategy
  • For patients with moderate-to-severe PFB, no shaving is recommended. They may be best served by always having a beard
  • Daily lifting out of any ingrowing hairs with a needle, beard pick, or pointed toothpick is required. Brisk washing of the affected area with an exfoliating sponge or face cloth may also dislodge early ingrowing hairs. Do not pluck out hairs; simply lift out the ingrowing end
  • Topical agents like benzoyl peroxide (to dry up pustules), topical retinoic acid, or mild keratolytic lotion (such as salicylic acid or glycolic acid) may be of some additional benefit and may be added to the shaving regimen
  • Hydrocortisone 1% cream or lotion should be applied after shaving (and twice daily), no matter what shaving technique is used. It reduces beard irritation
  • If patients with active pustulation or moderate-to-severe involvement want to attempt shaving in the future, they must first grow a beard for 2-12 weeks to allow the bumps already present to resolve. During this period, aggressive dislodgement of ingrowing hairs is performed
  • Superficial chemical peels (such as glycolic acid or salicylic acid) may be a helpful adjunctive treatment for individuals with PFB and may also reduce secondary hyperpigmentation associated with this condition
  • Laser epilation should always be considered as an important therapeutic option, where possible

Treatment pitfalls to remain vigilant of with this approach include:

  • PFB may be misdiagnosed as acne vulgaris, pyoderma or razor 'allergy'. If there is any doubt, refer the patient for evaluation
  • Do not be disappointed by therapeutic failure. Work with the patient (and employer if necessary, if having facial hair is a concern) and individualize the therapeutic plan, including hair removal
  • Post-inflammatory hyperpigmentation may occur from the PFB or from irritating topicals (i.e. depilatories, benzoyl peroxide or retinoic acid)

Further reading

Bridgeman-Shah S. The medical and surgical therapy of pseudofolliculitis barbae. Derm Therapy 2004;17:158-63.

Luelmo-Aguilar J, Santandreu MS. Folliculitis: recognition and management. Am J Clin Dermatol 2004;5:301-10.

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