Monday, June 14, 2010
Pseudofolliculitis barbae (PFB) or razor bumps is a condition
commonly affecting black men (and women). It is caused by shaving,
and it resolves when shaving is stopped. It usually affects the
beard, but is also common in the pubic area of women who shave
their bikini line. There are several basic factors that make
management less than ideal: First, no method of shaving works for
all patients. Second, with time many patients learn the best
technique for them, but often only after several unsuccessful,
painful attempts. Finally, many PFB patients cannot be continuously
"clean shaven," which may interfere with certain forms of
employment. The severity of disease dictates the therapeutic
- For persons with moderate to severe PFB, no shaving is
recommended. They are best served by always having a beard.
- Patient education is a cornerstone of management and must be
detailed, honest, and repeated on subsequent visits. Control, not
cure, must be emphasized.
- Daily lifting out of any ingrowing hairs with a needle, beard
pick, or pointed toothpick is required. Brisk washing of the
affected area with a buff or face cloth may also dislodge early
ingrowing hairs. Do not pluck out hairs; simply lift out the
- Topical agents like benzoyl peroxide (to dry up pustules),
topical retinoic acid, or mild salicylic acid preparations may be
of some additional benefit and may be added to the shaving regimen,
- To reduce beard irritation, hydrocortisone 1% cream should be
applied after shaving and up to twice daily regardless of the
shaving technique used.
- In order to attempt future shaving, people with active
pustulation or moderate to severe involvement must first grow a
beard for 2-12 weeks to allow resolution of bumps already present.
During this period aggressive dislodgement of ingrowing hairs is
- There are three basic forms of shaving available to the PFB
patient: razors, depilatories, and clippers. Each method will be
discussed in detail below. PFB patients must take time when shaving
and follow instructions carefully.
a) Razor shaving: One of three types of blade razors may be used:
single-blade disposable, an adjustable razor set at the lowest
setting (least close shave), or a foil-guarded system (PFB shaving
system). All are effective, but the latter is probably the best.
Razor shaving is usually effective in those with mild-to-moderate
PFB. Electric razors are usually no better than blade razors.
Detailed instructions on the correct techniques are
(i) Dislodge all ingrown hairs.
(ii) Soak the beard with a shave cream for several minutes. Edge
Gel is an effective hydrating shave cream.
(iii) Shave with the grain using even, smooth strokes. Do not
press down with the razor.
(iv) Do not stretch the skin when shaving.
(v) Shave each area only once. Do not go back over areas to shave
(vi) Shave frequently enough to keep the beard hair an optimal
length: long enough to be out of the follicle, but short enough to
not be ingrowing. This varies from daily to every third day,
depending on the rate of the beard growth of the patient.
b) Depilatory shaving: Two forms of depilatories are available:
barium sulfide and calcium thiogylcolate. Depilatory shaving takes
time, is smelly, and is irritating. Due to their inherent
irritancy, depilatories can rarely be used more often than twice
weekly. Repeated applications enhance irritancy. It is generally
more effective than razor shaving in those with moderate to severe
Detailed instructions on the correct technique are
(i) Mix the powder with cool water and apply a thin coat to
one-fourth to one-half of the beard area. Applying to the whole
beard at one time may allow paste to remain on the skin too long
(ii) Remove as soon as the beard hairs are dissolved, usually 2-3
(iii) Scrape off the paste with a moist spatula or tongue blade
using short rapid strokes in the direction of beard growth.
(iv) Wash the area thoroughly with cool water and soap to remove
all residual paste. Residual depilatory will cause
(v) Repeat steps (i)-(iv) on the remaining beard areas.
(vi) Apply hydrocortisone 1% cream after shaving and twice
c) Clipper shaving: Most PFB patients will be able to trim their
beard with a triple "0" (zero) barber clippers with good results.
The result is approximately a 1/16-inch stubble ("5 o'clock
shadow"). Certain patients with mild-to-moderate PFB may be able to
shave closer, after clipping, with a rotary triple-headed razor. A
preshave is recommended when using clippers or rotary shavers.
- PFB may be misdiagnosed as acne vulgaris, pyoderma, or razor
"allergy." If there is any doubt refer the patient for
- Do not be disappointed by therapeutic failure. Work with the
patients (and their employers if necessary), and individualize
their shaving techniques.
- Postinflammatory hyperpigmentation may occur from the PFB, or
from irritating topicals (ie, depilatories, benzoyl peroxide, or