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Therapeutic Strategies

Pseudofolliculitis Barbae

Timothy Berger Bruce Wintroub

Monday, June 14, 2010

Razor Bumps

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 strategy.

First Steps

  1. For persons with moderate to severe PFB, no shaving is recommended. They are best served by always having a beard.
  2. Patient education is a cornerstone of management and must be detailed, honest, and repeated on subsequent visits. Control, not cure, must be emphasized.
  3. 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 ingrowing end.
  4. 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, described below.
  5. To reduce beard irritation, hydrocortisone 1% cream should be applied after shaving and up to twice daily regardless of the shaving technique used.
  6. 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 performed.
  7. 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 essential:
    (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 missed hairs.
    (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 PFB.
    Detailed instructions on the correct technique are essential:
    (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 before removal.
    (ii) Remove as soon as the beard hairs are dissolved, usually 2-3 minutes.
    (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 irritation.
    (v) Repeat steps (i)-(iv) on the remaining beard areas.
    (vi) Apply hydrocortisone 1% cream after shaving and twice daily.

    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.

Pitfalls

  1. PFB may be misdiagnosed as acne vulgaris, pyoderma, or razor "allergy." If there is any doubt refer the patient for evaluation.
  2. Do not be disappointed by therapeutic failure. Work with the patients (and their employers if necessary), and individualize their shaving techniques.
  3. Postinflammatory hyperpigmentation may occur from the PFB, or from irritating topicals (ie, depilatories, benzoyl peroxide, or retinoic acid).

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