Pseudofolliculitis of the Beard Treatment & Management

There is currently no standardized treatment for pseudofolliculitis barbae.  Conservative treatment options include complete cessation or decrease in shaving frequency from daily to two to three times a week.  Other treatment options include topical therapies, oral antibiotics, chemical depilatories and laser and high-intensity light source hair removal. ^[8]

Chemical depilatories

Chemical depilatories work by breaking the disulfide bonds in hair, which results in the hair being broken off bluntly at the follicular opening. ^[14]

Barium sulfide powder depilatories of about 2% strength can be made into a paste with water and applied to the beard area. This paste is removed after 3-5 minutes.

Calcium thioglycolate preparations come as powder, lotions, creams, and pastes. The mercaptan odor is often masked with fragrance. In rare cases, this fragrance can cause an allergic reaction. Calcium thioglycolate preparations take longer to work and are left on 10-15 minutes; chemical burns result if left on too long.

Chemical depilatories should not be used every day because they cause skin irritation. Every second or third day is an acceptable regimen. Irritation can be countered by using hydrocortisone cream. A lower pH or concentration, or a different brand, may also prove less irritating. Several products are available; therefore, trying a different product is encouraged if one depilatory proves to be unacceptable.

Topical medications

Topically applied tretinoin (Retin-A) has shown promise for some patients. When used nightly, it alleviates hyperkeratosis. It may remove the thin covering of epidermis that the hair becomes embedded in upon emerging from the follicle. ^{[15, 16]}

Topical combination cream (tretinoin 0.05%, fluocinolone acetonide 0.01%, and hydroquinone 4%) (Triluma) has been shown to provide some benefit by targeting the hyperkeratosis (tretinoin), inflammation (fluocinolone), and postinflammatory hyperpigmentation (hydroquinone). ^[17]

Mild topical corticosteroid creams reduce inflammation of papular lesions. ^[15]

Topical eflornithine HCL 13.9% cream (Vaniqa) has been used for excessive facial hair and in patients with pseudofolliculitis barbae. It is also used as a combination with laser therapy for hirsute women and pseudofolliculitis barbae patients. It decreases the rate of hair growth. In addition, the treated hair may become finer and lighter. ^[18]

Antibiotics

For severe cases of pseudofolliculitis barbae with pustules and abscess formation, topical and oral antibiotics may be indicated. ^{[19, 20]}

Topical antibiotics may successfully reduce skin bacteria and treat secondary infection. These topicals include erythromycin, clindamycin, and combination clindamycin/benzoyl peroxide (Benzaclin, Duac) and erythromycin/benzoyl peroxide (Benzamycin) agents. Applying one of these agents once or twice per day is effective. Benzoyl peroxide applied topically once a day is also effective in reducing bacterial populations. It should be used sparingly and may be irritating to sensitive skin. It is a good first-line topical agent for persons with oily skin. Benzamycin is a combination of erythromycin and benzoyl peroxide. A once daily application has the benefits of both agents.

If pustules or abscess formation is evident, an oral antibiotic is indicated. Tetracycline is a common choice for a systemic antibiotic. Similar to a standard acne regimen, a dose of 500 mg twice a day used initially for 1-3 months is often effective.

Special considerations

Pseudofolliculitis barbae is of particular concern in persons in the military. Enforcement of a clean-shaven face in those with this condition can cause scarring, hyperpigmentation, secondary infection, and keloid formation. The lack of understanding of this disease has created tension and hostility between soldiers and their chain of command. Proper education on shaving methods and treatment of pseudofolliculitis barbae, including judicious breaks from shaving (no shaving profiles), is essential. ^{[21, 22, 23]}

Newer hair removal lasers may have a role in the treatment of pseudofolliculitis barbae. The problem with most laser and high-intensity light source hair removal modalities is that the natural skin pigment may be damaged by the laser because melanin in the hair shaft is the target chromophore. Devices being studied at this time may avoid this depigmenting complication. Diode laser treatments have been proven safe and effective in patients with skin phototypes I-IV. ^{[24, 25, 26, 27]}

The use of long-pulsed Nd:Yag laser in the treatment of pseudofolliculitis barbae demonstrated a decrease in papule formation, miniaturization, and reduction of hair counts in skin types IV, V and VI. ^[28] Most subjects had a return of normal hair growth after 6 months; however, 2 of 10 individuals had areas of permanent hair loss after 12-month follow-up. Adverse effects of long-standing hypopigmentation in this study were isolated, signifying that this particular laser is an encouraging modality of therapy. ^[29]

Reportedly, excellent results can be obtained with the use of an 800-nm diode laser technique with low power and high pulse duration (5-15 J/cm², 2 Hz, 100–400 ms), especially in darker-skinned individuals. ^[30]

Combined Therapy

In a small study of 40 male patients, Shokeir et al compared the outcomes of pseudofolliculitis barbae treatments with topical eflornithine cream monotherapy twice daily for 16 weeks, long-pulsed Nd-YAG laser for 4 sessions 4-week interval or combined simultaneous treatment with both.  After the initial 16 weeks of treatment, the combination therapy significantly higher mean improvement percentages of the inflammatory papules compared with either mono therapy. ^[31]

Hair-releasing procedures and shaving should be performed after a shower to hydrate and soften both the skin and the hair. Subsequent shaving results in a duller, rounded tip to the hair, which is less likely to reenter the skin.

Wash the beard with a face cloth, a wet sponge, or a soft-bristled toothbrush with a mild soap for several minutes using a circular motion. This technique helps to dislodge stubborn tips.

Using needles or toothpicks to dislodge stubborn tips is controversial. It usually is not recommended because overly aggressive digging with sharp objects can cause further damage to the skin.

Patients with pseudofolliculitis barbae may use razors if single-edged, foil-guarded, safety razors are used. ^[32] Double, triple, or quadruple-bladed razors shave too closely and should not be used. Commercially available foil-guarded razors have about 30% of the blade covered by foil, which prevents the blade from shaving the hair too closely.

Electric razors have acceptable results if used properly. The recommended technique with a 3-headed rotary electric razor is to keep the heads slightly off the surface of the skin and to shave in a slow, circular motion. Do not press the electric razor close to the skin or pull the skin taut because this results in too close of a shave. Some electric razors have "dial in" settings for the closeness of the shave. These may be effective if kept off of the closest settings.

Electric clippers are effective for resistant cases of pseudofolliculitis barbae. With clippers, 1- to 2-mm stubble can be left on the face. The tendency to shave too closely is reduced with this method, making it more effective. The appearance of stubble may be cosmetically unacceptable for some patients.