Razor Bumps (Pseudofolliculitis Barbae)

About Pseudofolliculits Barbae (razor bumps)

Pseudofolliculitis barbae (PFB) is commonly known as razor or shaving bumps. It is an inflammatory reaction to an ingrown hair, appearing as papules and pustules in a shaved area. Each lesion appears as a flesh-colored to erythematous papule with a hair shaft visible at its center. It is most common in men with curly hair. It is particularly prevalent in African American men but anyone can develop PFB. Shaving bumps can occur in any shaved location, including legs, back of the neck, and the pubic area (pseudofolliculitis pubis.). PFB can occur when either a hair curves back and re-enters the skin, or when a sharp-tipped hair pierces the follicle wall while growing. Typically, a recently shaved hair is left with a sharp point which reenters the skin as it grows in a curved fashion. Certain shaving methods that result in hair clipped below the skin surface make it more likely that a sharp-tipped hair will grow out and pierce the follicle wall. Pulling the skin taut, shaving against the grain, plucking hairs with tweezers or other instruments, electrolysis, and the use of double- or triple-bladed razors can all contribute to PFB. PFB is not a serious medical condition, but it can be of cosmetic concern, resulting in scarring (including keloids), postinflammatory hyperpigmentation and secondary infection.

With what can pseudofolliculitis barbae be confused?

The main differential diagnoses of pseudofolliculitis barbae are acne, folliculitis, tinea barbae, and sarcoidosis.

How is pseudofolliculitis barbae diagnosed?

PFB is usually diagnosed clinically by your dermatologist. Patients typically will complain of painful papules or pustules that occur after shaving.  Upon questioning, the patient may disclose one of the shaving techniques described above that predispose to PFB.  Pustules may be present from secondary infection, and scars, keloids, or postinflammatory hyperpigmentation may be observed.

How is pseudofolliculitis barbae treated?

Pseudofolliculitis barbae is treated by first stopping the cause of ingrown hair and then dealing with any resulting cosmetic deficits that may exist from long-standing lesions. A number of approaches are possible:

Chemical depilatories. Chemical depilatories disrupt the bonds that hold a hair shaft together.  The breakage is blunt rather than sharp, reducing the chance that a barbed hair will re-enter the skin. These products usually contain highly alkaline chemicals, primarily calcium thioglycolate, calcium hydroxide, and sodium hydroxide, such as in Nair.   Hydrocortisone cream can be used for resulting irritation.  Contact time should be about 10 minutes to avoid a chemical burn, but each product’s label should be reviewed carefully before use.

Tretinoin.  Topical retinoids (e.g. Retin-A) has proven beneficial.  It reduces hyperkeratosis and normalizes skin biology, possibly allowing the hair to free itself.  Combination products (e.g. TriLuma) that include a retinoid, a steroid (for inflammation), and hydroquinone (for hyperpigmentation) are convenient and often effective.

Antibiotics.  Severe cases with secondary infection may require topical or oral antibiotics, of the same varieties typically used for acne (topical erythromycin, clindamycin and/or benzoyl peroxide, and oral tetracyclines.)

Eflornithine. Topical eflornithine HCL cream (e.g. Vaniqa) decreases the rate of hair growth.

Laser hair reduction. Destruction of the hair follicle with a laser is an effective and sometimes long-lasting treatment. The diode laser and the long pulsed Nd:Yag lasers are commonly employed.

Prevention of PFB

A proper shaving regimen is critical for avoidance of pseudofolliculitis barbae.

  • Hydrate and soften the hair before shaving, such as in a warm shower.
  • Wash the beard with a soft wash cloth with mild soap and water using a circular motion to dislodge hair tips.
  • DO NOT attempt to pick out hair tips with a needle or other implement. This can result in scarring and should be done by your dermatologist or skin care professional.
  • Use only single-edged razor blades or foil-guard razors.  Double- or triple-bladed razors result in too close a shave and should be avoided.
  • The use of an electric razor can decrease PFB, but technique is important.  For the typical three-head rotary razor, shave in a slow circular motion with the heads not pressed tightly against the skin.   Do no pull the skin taut while shaving, as the shave may be too close, predisposing to PFB.
  • Leaving 1-2 mm of stubble is an effective cure for PFB.  Use electric clippers for this.  Stubble of this nature may not be acceptable for certain employment, and a medical note of necessity may be required.

What is the prognosis for pseudofolliculitis barbae?

There is no cure for PFB, but it can be managed and treated effectively.  Scarring, keloids, secondary infection, and postinflammatory hyperpigmentation can result if left untreated.

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Ingrown Hair

About ingrown hairs

An ingrown hair occurs when a hair curves back onto the skin and penetrates it.  The hair can then cause a brisk reaction in the skin, resulting in inflammation and possibly infection.  It usually appears as a skin-colored to red papule, sometimes with hyperpigmentation in chronic lesions.  Often, the hair can be seen centrally.  It is most common among those with curly hairs, and occurs with particular frequency in African American men, especially in the beard area and the occipital scalp.   The legs and bikini area in women are also frequently affected.  The condition can occur anywhere where the hair is shaved or broken off leaving a sharp tipped shaft.  This can occur after shaving or waxing.  Tight clothing has also been implicated.  An ingrown hair can also result from an occluded follicle, in which the growing hair is prevented from exiting.  Ingrown hairs can itch, or be angrily inflamed, red, and drain pus.

Razor bumps, or pseudofolliculitis barbae, is a form of ingrown hair and is addressed in a separate entry.

With what can an ingrown hair be confused?

The diagnosis is usually made clinically, but biopsy is sometimes necessary. Folliculitis, acne, keratosis pilaris, cysts, and abscesses are the most common differential diagnoses to consider.

How are ingrown hairs treated?

Ingrown hairs can be tweezed out.  Warm soaks are also helpful in dislodging the hairs.  Various acidic preparations and depilatories can be applied as well, which also my help prevent recurrence.  Eflornithine, which slows or prevents hair growth, can be used with similar purpose.  Topical retinoids, corticosteroids,and  topical and oral antibiotics can lead to improvement. Laser hair reduction for chronically affected areas may also be helpful, as can conventional electrolysis. Education on proper shaving technique is essential to reduce recurrence.  Untreated, the condition can result in scarring, keloids, prurigo nodularis, sinus tracts, and hyperpigmentation.

Tips for avoiding ingrown hairs

  • Wet hair for a while before shaving to soften it up and dull the hair.
  • Gently scrub the area with a soft brush or washcloth to help dislodge any stuck hairs.
  • Do not shave against the grain of the hair.
  • Do not shave too closely to the skin.
  • Leave a short stubble, if possible.
  • Allow the hair to grow out, if possible
  • Tweeze with a sterile tweezer and needle, following alcohol prep.  This is best left to a professional, as scarring can result if done inappropriately.

What is the prognosis for ingrown hairs?

Some ingrown hairs will resolve spontaneously.  Others if untreated may get infected, or lead to scarring and hyperpigmentation.

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