Pseudofolliculitis barbae

INTRODUCTION — Pseudofolliculitis barbae (pseudofolliculitis of the beard), often colloquially referred to as "razor bumps," "shave bumps," or "ingrown hairs," is a common cutaneous condition that develops as a result of the removal of facial hair. Pseudofolliculitis barbae most frequently occurs in association with shaving and results from an inflammatory response to the cutaneous entrapment of recently cut, short hairs.

Pseudofolliculitis barbae typically presents with firm papules and pustules in the beard area (picture 1A-C). Postinflammatory hyperpigmentation, secondary bacterial infection, scarring, and keloid formation are potential complications (picture 1A, 1D).

The pathogenesis, diagnosis, and management of pseudofolliculitis barbae will be reviewed here (algorithm 1). Infectious folliculitis is reviewed separately.

●(See "Infectious folliculitis".)

EPIDEMIOLOGY — As a condition associated with the removal of facial hair, pseudofolliculitis barbae is most prevalent in postpubertal males, with a predilection for populations with naturally curly hair [1]. In one study in the United States military, where a clean-shaven appearance is a component of military grooming standards, pseudofolliculitis barbae was detected in 45 percent of 50 Black males hospitalized for other indications, a rate considered to be much higher than the prevalence in White military service members [2-4]. Pseudofolliculitis barbae can also occur in females who remove facial hair and in association with frequent facial shaving in transfeminine individuals [5]. (See 'Pathogenesis' below.)

PATHOGENESIS — Although shaving is commonly associated with pseudofolliculitis barbae, other hair removal techniques (eg, plucking, waxing) may result in the development of this condition [6].

The clinical findings of pseudofolliculitis result from a cutaneous, inflammatory reaction against hair that has penetrated the interfollicular skin. This may occur through two mechanisms: extrafollicular and transfollicular penetration of the skin.

●Extrafollicular penetration – Extrafollicular penetration describes entry of the distal end of a hair into the interfollicular skin after it has already exited the follicular orifice (figure 1) [6]. This occurs when the distal end of a hair comes in contact with the surface of the skin. Shaving contributes to extrafollicular penetration by creating short, sharp-ended hairs that are capable of penetrating the skin.

●Transfollicular penetration – Transfollicular penetration occurs when the distal end of a hair penetrates the dermis prior to exiting the follicular orifice (figure 2) [6]. This event has been postulated to result from shaving techniques that result in retraction of the cut edge of the hair into the follicle, which can occur when the skin is stretched during shaving. Another theory is that the use of double-edged or multiple-edged razors may contribute to transfollicular penetration. The first razor edge pulls the hair upward, and the subsequent razor edge cuts the hair, resulting in retraction of the cut hair into the skin after shaving [6].

After entry into the interfollicular skin, the distal end of the hair may penetrate 2 to 3 mm into the dermis [7]. Eventually, continued hair growth leads to the spontaneous release of the embedded distal tip of the hair; this usually occurs within three to six weeks [7,8].

The predominance of pseudofolliculitis barbae in Black individuals is considered attributable to the prevalence of tightly curled hair in this population. The ends of tightly curled hair have a greater tendency to curve back towards the surface of the skin [9]. In addition, in individuals with tightly curled hair, the hair follicle sits at an oblique angle to the skin, which may contribute to the formation of sharp-tipped hairs during shaving [6]. One study identified a defect in a hair follicle keratin gene (K6hf) as a potential additional risk factor for this condition [9]. (See 'Epidemiology' above.)

CLINICAL FEATURES — Papules and pustules in sites of hair removal are the characteristic lesions of pseudofolliculitis barbae:

●Skin lesions – The 2 to 5 mm, firm papules may be skin colored, erythematous, or hyperpigmented (picture 1A-C). Loops of hair emerging from the follicular orifice and re-entering the skin may be visible on the skin surface (picture 2). New papules may develop one to two days following an inciting shave [3]. Individual papules may persist for several weeks, until resolving after spontaneous or intentional freeing of embedded hair.

Pustules may develop as a result of a sterile, acute, inflammatory response to embedded hair or as a manifestation of secondary infection [6].

●Distribution – The extent of involvement varies widely, from patients with fewer than a dozen papules and pustules to patients with more than 100 lesions. The anterior neck, mandible, cheeks, and chin are the most common sites for involvement. Mustache and sideburn regions are typically spared [7]. Individuals who remove hair from sites such as the axilla, pubic area, and legs may develop pseudofolliculitis in these areas [6,10].

●Symptoms and complications – Pruritus is common, and scratching can lead to bacterial superinfection. Hyperpigmentation or keloidal scarring may develop at sites of involvement in susceptible patients (picture 1A, 1D). (See 'Complications' below.)

HISTOPATHOLOGY — Histopathologic findings of pseudofolliculitis barbae include [6]:

●Intraepidermal neutrophils

●Foci of abscess formation in the dermis

●Granulomatous inflammation with foreign-body giant cells surrounding the tip of penetrating hairs

DIAGNOSIS — The diagnosis of pseudofolliculitis barbae is made based upon the history and physical findings. In general, a skin biopsy is not necessary.

History and physical examination — The patient history should include a review of the patient's hair removal practices and any observed associations between lesion development and hair removal. Expected physical examination findings include skin-colored, erythematous, or hyperpigmented papules and/or pustules limited to sites of prior terminal hair removal (picture 1A-C). Dermoscopic examination facilitates the visualization of characteristic embedded hairs (picture 2). (See 'Clinical features' above.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of pseudofolliculitis barbae includes other conditions that may result in papules or pustules in areas of terminal hair growth. Examples include:

●Bacterial folliculitis – Bacterial folliculitis usually presents as an acute condition with pustules and erythematous papules as the primary features (picture 3A-B). This contrasts with the chronic course and firm papules characteristic of pseudofolliculitis barbae. Cultures are useful for diagnosing bacterial folliculitis. In pseudofolliculitis barbae, cultures are usually negative or demonstrate normal skin flora in the absence of secondary infection [6,8,11]. (See "Infectious folliculitis", section on 'Bacterial folliculitis'.)

●Traumatic folliculitis – Traumatic folliculitis describes transient inflammation of the hair follicle due to irritation from shaving too closely [7]. Patients present with perifollicular, erythematous papules and excoriations. Unlike pseudofolliculitis barbae, the condition usually subsides rapidly (within a few days) if shaving is discontinued.

●Tinea barbae – Dermatophyte infections involving the beard area are referred to as "tinea barbae." Patients may present with pustules; inflammatory papules and nodules; or scaly, erythematous plaques (picture 4A-B). The detection of fungal forms on a potassium hydroxide preparation or, rarely, a punch biopsy confirms the diagnosis. (See "Infectious folliculitis", section on 'Dermatophytic folliculitis'.)

●Acne keloidalis nuchae – Acne keloidalis nuchae is a hair and scalp disorder that may present with dome-shaped papules, pustules, and keloidal plaques on the occipital scalp (picture 5). The location of acne keloidalis on the scalp distinguishes this condition from pseudofolliculitis barbae. (See "Acne keloidalis nuchae: Pathogenesis, clinical manifestations, and diagnosis".)

●Cutaneous sarcoidosis – Cutaneous sarcoidosis may present with a variety of manifestations, including firm papules or plaques that may be skin colored, yellow-brown, red-brown, violaceous, or hypopigmented (picture 6A-B). Unlike pseudofolliculitis barbae, embedded hairs are not a feature of cutaneous sarcoidosis, and lesions may be seen outside of the beard area. (See "Cutaneous manifestations of sarcoidosis", section on 'Specific lesions'.)

MANAGEMENT — Few randomized trials have evaluated interventions for pseudofolliculitis barbae. The approach to management is primarily guided by clinical experience (algorithm 1).

Overview — The primary approach to therapy for pseudofolliculitis barbae consists of interventions to minimize entry of hair into the interfollicular skin, which is considered the major contributory factory to pseudofolliculitis barbae. The most effective intervention is the permanent discontinuation of shaving or other hair removal practices that contribute to the condition. (See 'Patients for whom hair regrowth is acceptable' below.)

However, occupational requirements, cultural values, and individual preferences prevent many patients from discontinuing hair removal indefinitely. For these patients, adjusting hair removal practices and incorporating topical therapy may help to improve control of the condition [1,12]. Laser hair removal is an option when these interventions are insufficient. (See 'Patients for whom hair regrowth is not acceptable' below and 'Refractory disease' below.)

Patients for whom hair regrowth is acceptable — Discontinuing the inciting cause of pseudofolliculitis barbae (eg, shaving, hair waxing, or hair plucking) and allowing the hair to remain at a length that makes penetration of the skin unlikely is the treatment of choice for pseudofolliculitis barbae (algorithm 1).

Cessation of the inciting hair removal practice — Depending on the severity of the condition, marked improvement in papules and pustules is usually noted within one to six months after ceasing hair removal [6]. Associated hyperpigmentation may take several months or longer to resolve. (See 'Hyperpigmentation' below.)

Patients may continue to groom the beard with scissors or an electric clipper. We suggest initially trimming the hair to a length of no less than 0.5 cm. Trials of shorter trim lengths can be performed after the patient attains lesion clearance.

Pseudofolliculitis may continue to progress during the first few weeks after the discontinuation of shaving due to the continued embedding of previously shaved hairs in the skin [7,8]. In the interim, the distal tips of visible, embedded hairs may be carefully dislodged by the patient with a toothpick or sterile needle. Hair should not be plucked from the follicle because doing so may cause additional irritation [7].

Treatment of acute lesions — Low-potency topical corticosteroids may be helpful for reducing inflammation. Patients with highly inflamed lesions may benefit from intralesional corticosteroid injections. (See 'Treatment of acute lesions' below.)

Secondary infection should be treated with appropriate antibiotic therapy. (See 'Secondary infection' below.)

Patients for whom hair regrowth is not acceptable — Therapy for these patients involves short-term cessation of the inciting hair removal process (if possible), adjustments to hair removal methods, and anti-inflammatory therapy for acutely inflamed lesions (algorithm 1). In addition, long-term adjunctive treatment with topical antimicrobial agents and topical retinoids is often incorporated based upon limited data that suggest benefit in pseudofolliculitis barbae. (See 'Short-term cessation of hair removal' below and 'Adjusting hair removal methods' below and 'Treatment of acute lesions' below and 'Adjunctive topical therapy' below.)

Laser hair removal is an option for patients who fail to improve with these measures or prefer to proceed directly to this procedure as a long-term solution. (See 'Refractory disease' below.)

Short-term cessation of hair removal — When feasible, we encourage patients who are unable to permanently cease shaving to discontinue shaving until the condition improves (usually one to six months). Subsequently, changes in hair removal practices that may reduce the risk for recurrent pseudofolliculitis can be implemented. Patients who are unable to discontinue hair removal for this transient period can implement such measures immediately. (See 'Adjusting hair removal methods' below.)

Adjusting hair removal methods — Changes that may be helpful include adjustments to the shaving procedure and replacement of razor use with electric clippers or depilatories. The relative efficacy of these interventions is unclear; thus, selection among these measures is based upon patient preference. If a particular intervention does not yield improvement, one of the other approaches may be implemented (algorithm 1). (See 'Shave procedure' below and 'Electric clippers' below and 'Chemical depilatories' below.)

Shave procedure — Clinical experience suggests that adjustments to the shaving routine, particularly preshave and postshave interventions, can be useful for pseudofolliculitis barbae. In the authors' experience, the incorporation of moisture before shaving has seemed particularly beneficial:

●Incorporation of moisture – The application of generous amounts of a highly lubricating shaving cream or gel for 5 to 10 minutes prior to shaving softens the hair and may help to reduce the formation of sharp hair tips during shaving. Application of warm compresses prior to shaving is an alternative approach [7].

●Freeing of embedded hairs – Gentle washing of the beard area in a circular motion with a mildly abrasive cloth, sponge, or shaving brush for a few minutes daily may help to free embedded hairs [6,13,14]. Some authors have advocated using a magnifying mirror to identify embedded hairs, after which the embedded distal tips can be dislodged with a toothpick or sterile needle [6,15]. Plucking of hairs from the follicle should be avoided since this may lead to follicular inflammation and the subsequent growth of hair that penetrates the follicular wall [7,8].

●Razor choice, shave direction, and shave frequency – Shaving in the direction of hair growth (ie, "with the grain") and reducing the frequency of shaving are sometimes advised. However, the efficacy of these approaches is unproven, and some authors suggest otherwise [1,16,17]. Avoidance of stretching of the skin during shaving and use of a razor with a skin guard has also been suggested [13,18]. Additional study is necessary to clarify preferred shave methods.

One 12-week trial in which 90 patients with pseudofolliculitis barbae were randomly assigned to one of three treatment groups (shaving two to three times per week with a three-blade razor and standard products [cleanser, moisturizer, shaving gel], shaving daily with a five-blade razor and standard products, or shaving daily with a five-blade razor and advanced products) did not find significant differences among the three groups in outcomes of papule or pustule counts or investigator-assessed response to treatment [17].

Electric clippers — Electric clippers can be used to shave hair in a manner that leaves the remaining hair at a greater length than razor shaves. Patients are encouraged to leave the remaining hair at a length of at least 1 mm to reduce the risk of lesion recurrence [6]. The stubbled appearance associated with residual short hairs may not be acceptable to some patients [13].

Chemical depilatories — Clinical experience suggests some patients with pseudofolliculitis barbae improve when use of chemical depilatories replaces shaving. Chemical depilatories contain substances such as barium sulfide or calcium thioglycolate and remove hair by inducing the lysis of disulfide bonds in hair [8]. Hair removal with chemical depilatories tends to leave the distal ends of hairs with soft, brush-like tips rather than the sharp tips produced by shaving [7]. (See "Removal of unwanted hair", section on 'Depilation'.)

Chemical depilatory creams are usually applied to the skin for several minutes. Long hair in the treatment area should be clipped prior to use.

Irritation is a potential side effect of depilatories, and some patients are unable to tolerate these products on facial skin [19]. Patients should test the product on a nonfacial area and follow the site for irritation for 48 hours prior to facial use [7]. If significant irritation occurs, the product should not be used. Limiting the frequency of use to every other day or less may help to minimize irritation [2,6].

Treatment of acute lesions — Clinical experience suggests low-potency topical corticosteroids (group 6 or 7) are helpful for inflamed lesions (table 1) [7].

Topical corticosteroids are applied to inflamed lesions once or twice daily. Due to the potential for adverse effects on the skin, the treatment course is usually limited to less than three to four weeks on a particular area. An intralesional corticosteroid injection (eg, triamcinolone acetonide in a concentration of 2 to 3 mg/mL) is an alternative approach for larger, highly inflamed papules [13]. (See "Topical corticosteroids: Use and adverse effects", section on 'Adverse effects' and "Intralesional corticosteroid injection".)

Oral tetracyclines (eg, subantimicrobial doses of doxycycline) are occasionally incorporated for patients with marked inflammation based upon anti-inflammatory benefit observed in other cutaneous disorders [1,12,20]. However, data to confirm efficacy of this approach are lacking.

Secondary infection should be treated with appropriate antibiotic therapy. (See 'Secondary infection' below.)

Adjunctive topical therapy — Data are limited on the efficacy of other medical therapies for pseudofolliculitis barbae. The most common adjunctive medical therapies for pseudofolliculitis barbae are topical antimicrobials (eg, benzoyl peroxide with or without clindamycin) and topical retinoids (eg, tretinoin, adapalene) (algorithm 1). Further studies are necessary to clarify the efficacy of these agents. We usually incorporate these drugs in an attempt to achieve additional benefit.

Combination products containing both an antimicrobial and a topical retinoid can simplify the application regimen (table 2). If tolerance is a concern or the presentation is mild, an alternative approach is to start with an antimicrobial (eg, benzoyl peroxide with or without clindamycin) or retinoid, with subsequent addition of the second agent, if needed.

Continued treatment with these therapies is generally necessary for patients who respond if the inciting hair removal process is continued. In our experience, topical glycolic acid can be used as an alternative to a topical retinoid for maintenance of improvement:

●Topical antimicrobials – Since pseudofolliculitis barbae is not an infectious condition, authors have disagreed on the indications for antimicrobial therapy. While some authors have primarily limited use to the setting of secondary infection [7,15], others have used these agents routinely based upon the idea that antibiotics may reduce skin flora that may aggravate inflammation or lead to secondary infection [6,15,21].

Benzoyl peroxide 2.5 to 6% is commonly used alone or in conjunction with a topical antibiotic, such as clindamycin 1% or erythromycin 2%. Long-term use of topical antibiotics in the absence of benzoyl peroxide is not advised based upon concern for promoting antibiotic resistance [1].

A 10-week, randomized trial comparing the efficacy of a gel containing 5% benzoyl peroxide and 1% clindamycin with a vehicle gel in males using a specialized razor for pseudofolliculitis barbae suggests that antimicrobial therapy may accelerate improvement [22]. The reduction in lesion counts was greater in the active treatment group than in the placebo group at two, four, or six weeks after treatment. However, the difference between the groups was no longer statistically significant at week 10.

●Topical retinoids – Topical retinoids, such as tretinoin, adapalene, or tazarotene, are applied to the affected region once daily in the evening. Starting with a lower concentration of a specific retinoid and/or an application frequency of every other night to every third night may help to minimize retinoid-induced skin irritation. (See "Acne vulgaris: Overview of management", section on 'Skin of color'.)

Two small, uncontrolled studies have documented clinical improvement in patients treated with daily application of topical tretinoin for several weeks, one of which involved the use of tretinoin in combination with a low-potency topical corticosteroid [11,23]. The rationale for a benefit of topical retinoids in pseudofolliculitis is uncertain; some authors have postulated that retinoids may improve follicular hyperkeratosis, which might contribute to the development of the condition [11].

Topical retinoid therapy may also accelerate improvement of hyperpigmentation. (See 'Hyperpigmentation' below and "Postinflammatory hyperpigmentation", section on 'Topical retinoids'.)

●Glycolic acid – Topical glycolic acid products, such as glycolic acid 10% lotion, can be applied daily to the beard area. Two small, randomized trials support benefit of twice-daily application of 8% buffered glycolic acid for improving lesions of pseudofolliculitis barbae [24]. In addition, a trial in which 20 patients with pseudofolliculitis barbae were randomly assigned to up to five treatments with either a chemical peel with glycolic acid and trichloroacetic acid or a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser found clinical improvement with both therapies, with laser therapy the most effective therapy [25]. Similar to topical retinoids, the mechanism of benefit in pseudofolliculitis barbae is unclear. (See 'Laser hair removal' below.)

Refractory disease — Patients who want or need to continue hair removal but fail to respond to first-line interventions may benefit from laser hair removal (algorithm 1).

Laser hair removal — Laser hair removal works through selective destruction of hair follicles and results in a reduction in the density and thickness of hair. Multiple treatment sessions are usually required to achieve a major reduction in hair growth because only a minority of hair follicles are destroyed during each treatment. Limited data suggest that the addition of topical eflornithine may be beneficial (see "Removal of unwanted hair", section on 'Laser and intense pulsed light'):

●Treatment principles – Since melanin is the follicular component targeted by hair removal lasers, patients with darkly pigmented hairs are the best candidates for this procedure. The treatment is poorly effective for white or gray hairs. (See "Principles of laser and intense pulsed light for cutaneous lesions", section on 'Large versus small structures' and "Removal of unwanted hair", section on 'Laser and intense pulsed light'.)

Multiple lasers have demonstrated benefit for the treatment of pseudofolliculitis barbae, including long-pulsed Nd:YAG [26-31], diode [32-34], alexandrite [35], and ruby [36] lasers. As an example, in an open study in which 37 male patients with primarily mild pseudofolliculitis barbae had a 15 x 15 mm area in the submental region treated with one session with a long-pulsed Nd:YAG laser, examination 90 days after treatment revealed that mean papule counts were lower in the treated sites than in adjacent control sites (1.0±1.36 versus 6.9±5.25, respectively) [26].

Lasers should be selected carefully to minimize risk for adverse effects. Long wavelength lasers, such as the Nd:YAG laser, are generally a safer option for patients with highly pigmented skin [13].

●Precautions – Risks of laser hair removal include transient or permanent, pigmentary changes; blistering; and scarring. The risk for pigmentary abnormalities is greatest in individuals with highly pigmented skin. Performing a test spot in an inconspicuous area may reduce the risk for disfiguring side effects by allowing the clinician to adjust laser settings appropriately prior to treatment.

Patients should consider the permanent effects of laser hair removal; future hair regrowth is inhibited.

●Adjunctive eflornithine – Eflornithine is a topical agent used most commonly for the treatment of unwanted facial hair. The drug slows hair growth by inhibiting ornithine decarboxylase and is applied to areas of hair growth twice daily. Small, randomized trials suggest topical eflornithine may help to accelerate improvement in patients receiving laser therapy [27,31].

In a split-face, randomized trial, 27 male patients with pseudofolliculitis barbae were treated with a long-pulsed Nd:YAG laser every 4 weeks for 16 weeks [27]. In addition, the patients applied eflornithine 13.9% cream to one side of the face and a placebo cream to the other side of the face twice daily. Although greater improvement in papular lesions was noted on the side of the face treated with eflornithine at every study time point, excellent results were attained in both groups, and the clinical difference in improvement in papular lesions was negligible after 16 weeks. A trial that compared twice-daily eflornithine therapy with Nd:YAG laser therapy given every four weeks and combination Nd:YAG laser and eflornithine therapy in 40 patients with pseudofolliculitis barbae supports superiority of combination therapy for improving inflammatory papules at 16 weeks [31]. (See 'Other therapies' below.)

Other therapies — Additional treatments that have been used for pseudofolliculitis barbae include eflornithine and photodynamic therapy. Electrolysis as an alternative to laser hair removal generally is not recommended:

●Topical eflornithine – Although the use of this agent has been advocated by some authors [7,37,38], study data on the efficacy of twice-daily application of eflornithine for pseudofolliculitis barbae are limited.

A randomized trial (n = 40) that compared treatment with eflornithine alone with treatment with an Nd:YAG laser alone and with eflornithine and laser combination therapy supports benefit [31]. The trial found improvement in inflammatory papules in all three groups after 16 weeks, with combination therapy as the most effective intervention. The degree of improvement decreased in all groups during a 12-week, treatment-free, follow-up period.

●Photodynamic therapy – Photodynamic therapy was proposed as a potential treatment based upon a case report describing benefit in a patient with refractory staphylococcal folliculitis barbae and pseudofolliculitis barbae [39].

●Electrolysis/thermolysis – Electrolysis for permanent removal of beard hairs is generally not recommended for pseudofolliculitis barbae since it is painful, tedious, and often unsuccessful [6]. Exacerbation of pseudofolliculitis barbae is also a concern because failure of the electrolysis needle to reach the hair bulb of a curved hair follicle could theoretically result in an increased risk for subsequent transfollicular penetration during regrowth [6] (see 'Pathogenesis' above). Hyperpigmentation at sites of needle insertion and scarring are additional potential adverse effects of electrolysis. (See "Removal of unwanted hair", section on 'Electrolysis'.)

●Hormonal therapy – Some female patients with pseudofolliculitis barbae have hormonal abnormalities contributing to facial hair, suggesting hormonal therapy could be beneficial [20]. The effects of antiandrogenic therapy in female patients with pseudofolliculitis barbae have not been studied.

COMPLICATIONS — Hyperpigmentation, keloids, and secondary infection are potential complications of pseudofolliculitis barbae.

Hyperpigmentation — Postinflammatory hyperpigmentation commonly occurs in sites of pseudofolliculitis barbae (picture 1A). Topical treatments such as hydroquinone, topical retinoids, alpha-hydroxy or polyhydroxy (glycolic or lactic) acid lotions or polyhydroxy acid (lactobionic acid)-containing lotions, azelaic acid, kojic acid, and chemical peels can be helpful for accelerating improvement in the hyperpigmentation associated with this condition [15]. The treatment of postinflammatory hyperpigmentation is reviewed separately. (See "Postinflammatory hyperpigmentation", section on 'Treatment'.)

Keloids — Keloidal scarring may occur in susceptible patients and can become extensive in some patients (picture 1D). Achieving control of pseudofolliculitis barbae is critical in these patients to minimize additional scarring. The treatment of existing keloids is reviewed separately. (See "Keloids and hypertrophic scars".)

Secondary infection — Fluctuant lesions, purulent drainage, and worsening pain suggest the possibility of secondary infection. Appropriate management includes performance of cultures and administration of antibiotic therapy.

PSYCHOSOCIAL AND OCCUPATIONAL IMPACT — The discomfort and disfigurement associated with pseudofolliculitis barbae can negatively impact self-esteem and quality of life [13]. In addition, societal expectations and employment conditions that favor a "clean-shaven" appearance place individuals with pseudofolliculitis barbae at risk for career limitations and discrimination. The disproportionate medical and administrative effects of shaving requirements on Black military personnel has been a long-standing issue of concern in the United States military [2-4].

Places of employment that require shaving should consider the negative health effects of continued hair removal in patients with pseudofolliculitis barbae. Flexibility in hair grooming standards is essential for the optimal care of patients with pseudofolliculitis barbae.

Documentation of clinician support may be helpful for patients at risk for dismissal from a job or other negative career effects. This may include communication of the following principles:

●Pseudofolliculitis barbae is a chronic, inflammatory skin condition that is caused by hair removal.

●Pseudofolliculitis barbae can result in physical discomfort, scarring, disfigurement, and infection.

●Discontinuation of contributory hair removal practices (eg, shaving) is the most effective treatment for pseudofolliculitis barbae.

SUMMARY AND RECOMMENDATIONS

●Overview – Pseudofolliculitis barbae is a cutaneous, inflammatory disorder that results from hair removal (eg, shaving, waxing, or plucking). The disorder occurs most frequently in the beard area of postpubertal males with naturally curly hair. (See 'Epidemiology' above.)

●Pathogenesis – Pseudofolliculitis barbae reflects an inflammatory reaction to hair that penetrates the interfollicular skin. Regrowing hairs penetrate the skin after shaving or other methods of removal. Shaving may contribute to sharp-tipped hairs, increasing the risk for penetration. (See 'Pathogenesis' above.)

●Clinical features – Pseudofolliculitis barbae presents as 2 to 5 mm papules and pustules in sites of hair removal (picture 1A-C). The papules may be skin colored, erythematous, or hyperpigmented. Loops of hair emerging from the follicular orifice and re-entering the skin may be visible on the skin surface (picture 2). The anterior neck, mandible, cheeks, and chin are the most common sites for involvement. (See 'Clinical features' above.)

Postinflammatory hyperpigmentation, keloidal scarring, and secondary infection are potential complications (picture 1A, 1D). (See 'Complications' above.)

●Diagnosis – A diagnosis of pseudofolliculitis barbae is made based upon the history of hair removal and the recognition of consistent physical findings. (See 'Diagnosis' above.)

●Initial management – The feasibility of adjustments to hair removal practices influences the approach to treatment (algorithm 1):

•If cessation of close hair removal is feasible – The most effective therapy for pseudofolliculitis barbae is the permanent cessation of close hair removal and allowing the hair to remain at a length that reduces the risk of recurrence (at least 0.5 cm initially). Discontinuation of shaving often leads to improvement in pseudofolliculitis barbae within a few months. (See 'Patients for whom hair regrowth is not acceptable' above.)

•If cessation of close hair removal is not feasible – A multifaceted approach is taken for patients who cannot permanently cease close hair removal, including:

-Short-term cessation of close hair removal – When feasible, patients should discontinue close hair removal until the condition improves (usually one to six months). Subsequently, adjustments to hair removal techniques that may reduce the risk for recurrent pseudofolliculitis can be implemented. (See 'Short-term cessation of hair removal' above.)

-Adjustments to hair removal techniques – Preshave and postshave interventions, such as the routine incorporation of moisture and freeing of embedded hairs, may be beneficial for patients who must continue shaving. Transitioning from shaving to electric clippers or chemical depilatories may lead to improvement in some patients. (See 'Adjusting hair removal methods' above.)

-Adjunctive medical therapy – We suggest a topical antimicrobial agent and a topical retinoid as adjunctive treatment (Grade 2C). Options for topical antimicrobial therapy include benzoyl peroxide with or without clindamycin or erythromycin. (See 'Adjunctive topical therapy' above.)

•Treatment of acutely inflamed lesions – For acutely inflamed lesions, we suggest low-potency topical corticosteroids (Grade 2C). Intralesional corticosteroid injection is an alternative for larger, highly inflamed papules. (See 'Treatment of acute lesions' above.)

●Refractory disease – For patients who want or need to continue with hair removal but do not improve with initial interventions, we suggest laser hair removal rather than other therapies (algorithm 1) (Grade 2C). The addition of topical eflornithine to laser therapy may be beneficial. (See 'Refractory disease' above.)

●Psychosocial and occupational effects – Pseudofolliculitis barbae can negatively impact self-esteem and quality of life. Cessation of hair removal may place patients at risk for repercussions in the workplace. Providing support for the cessation of hair removal can be helpful for patients. (See 'Psychosocial and occupational impact' above.)