Folliculitis barbae and pseudofolliculitis barbae

What is folliculitis barbae?

Folliculitis barbae is a type of folliculitis affecting the beard area due to infection with the bacteria Staphylococcus aureus. It occurs in men who shave and in men that do not shave. Deep-seated folliculitis barbae is called sycosis barbae and leads to scarring and areas of permanent hair loss.

What is pseudofolliculitis barbae?

Pseudofolliculitis barbae is a foreign-body inflammatory reaction surrounding ingrown facial hairs, which results from shaving.  It can also occur on any body site where hair is shaved or plucked, including axilla, pubic area, and legs. It is also known as shaving rash or razor bumps.

Folliculitis barbae and pseudofolliculitis barbae can co-exist. 

Who gets folliculitis barbae and pseudofolliculitis barbae?

Prevalence of folliculitis barbae and pseudofolliculitis barbae is higher among males of African ancestry than among Caucasian men. Both disorders can also affect women of all races. They are associated with improper shaving practices and are more common when a blade razor is used rather than an electric shaver.

Recent research has confirmed a genetic predisposition to pseudofolliculitis in the African population. A single nucleotide substitution in the hair follicle companion layer-specific keratin (K6hf) is shown to increase the chance of pseudofolliculitis barbae. 

What causes pseudofolliculitis barbae?

Pseudofolliculitis barbae is due to shaving, particularly close shaving—because the cut hair may retract beneath the skin surface. It can also occur in skin folds and scars. It occurs mainly in people with curly hair because the curl of the hair means that the sharp pointed end of a recently shaved hair comes out from the skin and re-enters the skin close by causing a foreign body inflammatory reaction. 

The injured follicles are highly susceptible to become infected, causing folliculitis barbae. 

What are the features of pseudofolliculitis and folliculitis barbae?

After shaving, patients may experience an acne-like eruption on the area that has been shaved, usually the face and neck of men.

• Involvement of the skin under the jawline is typical, a site where the hair follicles grow in various directions.
• Pseudofolliculitis barbae presents as ingrown hairs associated with flesh-coloured or red follicular papules, which may be itchy or tender.
• Folliculitis barbae presents as painful pustules and can discharge pus.
• Lesions may bleed when they are shaved.

Folliculitis barbae and pseudofolliculitis are aggravated by co-existent eczema/dermatitis. 

What are the complications of folliculitis and pseudofolliculitis barbae?

Complications of folliculitis and pseudofolliculitis barbae include:

• Postinflammatory hyperpigmentation
• Hypertrophic scarring and keloid formation
• Temporary and permanent hair loss 
• Sycosis barbae – sinuses, abscesses and spreading infection due to infection and autoinflammatory reaction

How are pseudofolliculitis barbae and folliculitis barbae diagnosed?

Pseudofolliculitis barbae is a clinical diagnosis. Magnification, eg dermatoscopy, may be necessary to see the ingrown hairs. Folliculitis barbae is diagnosed by the presence of painful pustules.

Swabs may be taken for bacterial culture but are rarely necessary. 

What is the treatment?

Treatment for pseudofolliculitis barbae depends on the severity of the condition. If possible, let the beard grow for 30 days to eliminate ingrown hairs. When ready to shave again, take the following precautions:

• Ensure the skin is well moisturised, for example using a lotion containing glycolic acid to the affected areas. This exfoliates the surface skin cells and reduces the likelihood of new inflamed spots.
• Cleanse the skin using a polyester skin-cleansing pad or a moisturising shaving foam.
• Aim to have a 5 o'clock shadow immediately after shaving. Shave less frequently, eg every other day.
• Either use a single blade disposable razor or use electric hair clippers or a razor with an attachment that leaves the cut hairs long.
• Shave in the direction of the follicle, not against it. Do not stretch the skin.
• Sterilise metal hair clippers and electric razors using boiling water, and plastic items should be soaked in an antiseptic solution.

Medical treatment of pseudofolliculitis barbae

• Hydrocortisone cream can reduce mild inflammation and itching.
• Topical acne treatments such as benzoyl peroxide and tretinoin are used to suppress follicular hyperkeratosis.
• A combination of tretinoin, low-potency topical corticosteroid, and hydroquinone may be selected to decrease inflammation, hyperkeratosis and pigment production.
• Oral tetracyclines are used to reduce inflammation.
• Photodynamic therapy has been successful.

What is the treatment of folliculitis barbae?

As folliculitis barbae and sycosis barbae are due to bacterial infection, they are treated with topical or oral anti-staphylococcal antibiotics.

How is pseudofolliculitis barbae prevented?

To prevent recurrence, follow a proper shaving regimen long term and consider hair removal. Methods may include: 

• Eflornithine cream
• Chemical depilatories such as barium sulfide paste and calcium thioglycolate; these can be irritating
• Intense pulsed light (IPL)
• Laser hair removal, especially Nd:YAG and diode lasers, but there is a risk of causing white or dark marks in skin of colour.