Pseudofolliculitis barbae is irritation of the skin due to hairs that penetrate the skin before leaving the hair follicle or that leave the follicle and curve back into the skin, causing a foreign-body reaction.
Pseudofolliculitis barbae predominantly affects Black men. Risk factors include tightly curled hairs and certain keratin gene variations (KRT75, K6hf) (1, 2). It typically results from shaving.
Pseudofolliculitis barbae is most problematic around the beard and neck, hence the term "barbae," which refers to the beard. However, pseudofolliculitis can occur in women who shave, especially in the groin area, and anywhere hair is shaved or plucked. It causes small papules and pustules that can be confused with bacterial folliculitis. Scarring can eventually result.
Image provided by Thomas Habif, MD.
Photo courtesy of Karen McKoy, MD.
General references
1. Kniffin CL: Pseudofolliculitis barbae. Online Mendelian Inheritance in Man. Accessed March 28, 2024.
2. Winter H, Schissel D, Parry DA, et al: An unusual Ala12Thr polymorphism in the 1A alpha-helical segment of the companion layer-specific keratin K6hf: evidence for a risk factor in the etiology of the common hair disorder pseudofolliculitis barbae. J Invest Dermatol 122(3):652-657, 2004. doi: 10.1111/j.0022-202X.2004.22309.x
Diagnosis of Pseudofolliculitis Barbae
Examination
Diagnosis of pseudofolliculitis barbae is by physical examination.
Treatment of Pseudofolliculitis Barbae
Cessation of shaving
Warm compresses and retraction and release of ingrown hair tips
Topical or oral medications as needed for inflammation and secondary infection
Sometimes hair follicle removal
Sometimes prednisone
Shaving should be discontinued until all inflammatory lesions have cleared. Acute manifestations of pseudofolliculitis barbae (eg, papules and pustules) can be treated with warm compresses and manual retraction of ingrown hair tips with a sterile needle or toothpick to release embedded hairs. For most treatments, strong evidence is lacking, so regimens are based largely on clinical experience.
Topical hydrocortisone 1% or topical antibiotics can be used for mild inflammation. Oral doxycycline (50 to 100 mg 2 times a day) or oral erythromycin (250 mg 4 times a day, 333 mg 3 times a day, 500 mg 2 times a day) can be used for moderate to severe inflammation. Because inflammation, not infection, is being treated, there is no fixed duration for treatment withdoxycycline or erythromycin.
Tretinoin (retinoic acid) gel, liquid, or cream or benzoyl peroxide cream may also be effective in mild or moderate cases but may irritate the skin.
Topical eflornithine hydrochloride cream may help by slowing hair growth so that shaving can be done less frequently. Alternatively, hairs can be allowed to grow out; grown hairs can then be cut to about 0.5 cm in length.
Hair follicles can be permanently removed by electrolysis or laser treatment. Chemical depilatories may also be used because chemical removal of hairs does not trigger the pathology; however, it may irritate the skin.
A short course of prednisone may be necessary for resistant cases.
Once lesions clear and patients resume shaving, shaving techniques must be optimized.
