An Overview of Pseudofolliculitis Barbae

Pseudofolliculitis barbae (PFB) is a chronic inflammatory skin condition caused by hairs that grow into and under the skin. Common terms for this condition include razor bumps, shaving bumps, or ingrown hairs.

Pseudofolliculitis barbae is most often caused by hair removal, particularly shaving, because shaving cuts the hair into a sharp tip that can more easily penetrate the skin as it grows. The condition typically develops in the beard area of men, but it can occur in anyone and in any area where thick or coarse hair grows.

This article discusses the causes of pseudofolliculitis barbae, what it looks like, and how it can be prevented and treated.

Pseudofolliculitis Barbae Symptoms

Pseudofolliculitis barbae affects the hair follicles and surrounding skin in areas where terminal hair—the thicker, coarser hair that begins to develop after puberty—grows.

The condition is most common in the beard area (the lower cheeks, jawline, chin, and neck). PFB can also appear on the back of the neck, in the pubic area, and occasionally on the underarms, arms, or legs.

This condition develops after hair has been removed by either shaving (most commonly) or waxing.

Symptoms of pseudofolliculitis barbae include:

• Red, inflamed bumps (papules) that can be sore or painful, especially while shaving
• Itching
• Stinging
• Pustules (inflamed bumps with white or yellow "heads" that are filled with pus)

These symptoms may develop or worsen within a day or two after shaving.

More serious inflamed skin lesions, such as nodules and abscesses, may develop if the follicle becomes infected. Staphylococcus aureus, a type of bacteria, is the most common culprit.

Pseudofolliculitis also causes darkening of the skin in affected areas, a condition called post-inflammatory hyperpigmentation.

Hypertrophic (raised scars) or keloid scars can also develop in people who are prone to them.

Causes of Pseudofolliculitis Barbae

Pseudofolliculitis develops when terminal hair doesn't grow up and out of the hair follicle normally through the opening at the skin's surface, or pore. Instead, the hair grows sideways underneath the skin's surface, through the follicle wall, and into the surrounding skin tissue.

Sometimes the hair will exit the pore normally, but do a sharp "U-turn" and grow back into the skin from the surface.

There are three main factors that are particularly known to lead to the development of PFB:

• Having curly hair
• Being genetically prone to the condition
• Current hair grooming method

Curly Hair

Although it can happen in any hair type, pseudofolliculitis is by far more common in people with naturally curly hair. Tightly curled hair is more likely to twist back into the skin rather than growing up and out of the follicle.

Pseudofolliculitis barbae is incredibly common in Black men and men who have curly facial hair. It's estimated that up to 83% of all Black men develop pseudofolliculitis barbae.

Genetic Predisposition

Interestingly, some people are more prone to developing pseudofolliculitis barbae regardless of their hair texture.

An important 2004 study published in the Journal of Investigative Dermatology found that people who had a single substitution in a specific keratin gene (K6hf) were six times more likely to develop pseudofolliculitis barbae than those without this mutation.

Shaving

Even with the other factors, it is shaving (and less often, waxing) that is the initial trigger for pseudofolliculitis.

Hair stretches, just a bit, when shaving, especially if the skin is pulled taut. As the razor cuts, the hair pulls back and retracts into the follicle. This is why the skin feels perfectly smooth without a hint of stubble: The hair shaft has been cut not at the skin's surface, but just below it.

While this makes for a nice, close shave, it also sets up the perfect scenario for pseudofolliculitis to develop. The sharp, angled point that shaving creates at the tip of each hair can more easily pierce the skin as the hair grows.

Hair that is thick and coarse, being more robust than fine vellus hair, can also penetrate the skin more easily.

Other Possible Causes

Pseudofolliculitis barbae is more common in women with polycystic ovary syndrome (PCOS), and other hormonal disorders that cause hirsutism, or excessive facial hair. It is also more common in perimenopausal and menopausal women.

Other risk factors for pseudofolliculitis include taking cyclosporine or and corticosteroids (in renal transplant patients).

Diagnosis

PFB is diagnosed based on a review of symptoms and a visual inspection of the skin. There is no specific test for diagnosing pseudofolliculitis barbae.

Your healthcare provider may look at your skin using a dermoscope, a handheld instrument is similar to a magnifying glass. This tool is used to magnify the skin up to 10 times and allows the healthcare provider to see ingrown hairs under the skin's surface. They look like dark grey or black lines or spots under the skin.

In some cases, your healthcare provider may swab your skin to check for a bacterial infection.

Differential Diagnoses

In general, pseudofolliculitis is easy to diagnose, but there are other skin conditions that cause inflamed bumps. Sometimes these conditions can occur at the same time as PFB.

Skin conditions that resemble pseudofolliculitis barbae include:

• Tinea barbae: Tinea, better known as ringworm, is a fungal infection. It can occur anywhere on the skin. When it appears in the beard area it is called tinea barbae.
• Razor burn: Razor burn also appears after shaving, typically immediately after, and causes redness, burning, pain, and inflamed bumps. Unlike PFB, razor burn is not caused by ingrown hairs, but rather irritation from the friction caused by shaving. Razor burn improves a day or two after shaving, while pseudofolliculitis worsens a few days after shaving.
• Acne vulgaris: Pseudofolliculitis looks remarkably similar to acne vulgaris and is often confused with this skin issue. But there are differences between an ingrown hair and a pimple. More tellingly, PFB only appears in the areas where hair is thick or coarse, especially if you're shaving in that area. Acne occurs over the entire face.

Pseudofolliculitis Barbae Treatment

The best treatment for PFB is prevention. Arguably, the most effective way to prevent these ingrown hairs is to completely stop all methods of hair removal and let hair grow out.

At first, this may cause an increase in symptoms because the hair that has already been shaved or removed can become trapped under the skin. Over time, though, the skin improves because the grown-out hair stays above the skin's surface. Hence, it is much less likely for ingrown hairs to develop.

When you completely stop shaving, marked improvement is typically seen in about three months' time.

In many cases, stopping shaving will completely clear up pseudofolliculitis barbae. At this point, any treatment for post-inflammatory hyperpigmentation or scars can be started.

However, letting hair grow out isn't an option for everyone. You may have a job that requires you to be clean-shaven, for example. If that's true for you, there are other treatment options that can be used.

Shaving Tips

If you're prone to pseudofolliculitis barbae, proper shaving techniques will help to avoid irritation and reduce ingrown hair development. These tips can be used for all areas of the body, not just the face

• Preshave, hydrate the hair to soften. This can be done with a warm, damp towel (like how your skin is prepped for shave in the barbershop). At home, it's more practical to shave immediately after showering. This allows the skin and hair to be well hydrated and softened. Shaving hair in this state is more likely to produce a blunt tip, rather than a sharp end.
• Use moisturizing shaving cream or gels to give a shave with less drag. Friction can irritate the skin.
• Don't pull the skin taut when shaving. This gives you a closer shave, but that shouldn't what you're going for. When the skin is pulled taut, the hair is cut so close that it stretches and then retracts under the skin's surface. This makes ingrown hairs much more likely as the hair grows out.
• Use a single blade razor rather than one with multiple blades. Along the same lines, with a multiple blade razor, one blade pulls and stretches the hair while the other blade cuts the hair short enough to retract below the skin's surface. You may also get good results switching to an electric razor.
• Shave in the direction of hair growth rather than against the grain. Doing this won't give you as close of a shave, so you won't feel completely smooth. But it will keep the hair just above the surface of the skin so there is less chance of it turning and growing into the skin's tissue.
• Use clippers instead of a razor. This doesn't give you a close, clean shave, but rather keeps hair very short but above the skin's surface. It's recommended that you leave the hair at least 1 millimeter long. (Think of shaving to leave a 5 o'clock shadow.)

Chemical Depilatories

If you're not getting adaquate results, even with careful shaving techniques, you may wish to try chemical depilatories.

Chemical depilatories are creams that work by dissolving the hair shaft so that the hair can be rinsed or wiped away. This isn't a permanent means of getting rid of hair; it will grow back. But when it does, the hair itself has a softer, finer tip.

The downside is depilatories are messy and smelly. They can also be irritating for some people, causing burning and stinging during use. If you're particularly sensitive, they may also cause contact dermatitis.

Always use depilatories with care and follow all directions on the package.

Topical Exfoliants and Keratolytics

Exfoliants are products that loosen and remove dead skin cells on the skin's surface, allowing them to slough away. Keratolytics are a type of exfoliant that work by softening keratin (the chief protein that makes up hair, skin, and nails) and dissolving the bonds that hold dead skin cells together.

Regular use of exfolianting products helps to improve pseudofolliculitis barbae by reducing excess cells on the skin's surface that promote ingrown hairs. They are typically applied once or twice daily over all affected areas.

Options include:

• Alpha-hydroxy acids, including glycolic acid: These can be found in over-the-counter (OTC) products and in prescription creams. Glycolic acid, especially when used in peels, softens the bonds of the hair shaft, making the hair less able to penetrate the skin.
• Salicylic acid: Salicylic acid is found in OTC acne treatments. Stronger medications can be prescribed by a healthcare provider. In addition to topical medications, salicylic acid peels are beneficial.
• Topical retinoids: Topical retinoids included medications such as Retin-A (tretinoin) and Tazorac (tazarotene). These medications are available by prescription only.

Lightly exfoliating with an OTC scrub daily can help lift hairs that are already above the skin's surface, preventing them from growing back into the skin. OTC scrubs are most effective as a preventative measure in minor cases of pseudofolliculitis barbae, and only if the skin is not considerably inflamed.

Topical Steroids

Your healthcare provider may recommend topical steroids for short-term treatment to alleviate moderate to severe inflammation.

Over-the-counter hydrocortisone cream can reduce itching and inflammation. If OTC options aren't enough, you may be prescribed a stronger medication.

All topical steroids, including OTC hydrocortisone, should only be used on an as-needed basis and not as a long-term daily treatment, and only under the recommendation of a healthcare provider. Side effects include thinning of the skin and hypopigmentation, which is much more common in dark skin.

Procedures

These aren't used as a first-line defense against PFB. Instead, these procedures may be tried if pseudofolliculitis is severe and not responding well to other treatments.

• Laser hair removal: Laser light is directed at the hair follicles. This light destroys the hair follicle, slowing hair growth or completely preventing it from ever regrowing.
• Photodynamic therapy (PDT): During this procedure, a light-sensitizing fluid is applied to the skin. This area is then exposed to light. While this treatment is commonly used to treat acne and precancerous skin conditions, it isn't often used to treat pseudofolliculitis. However, it has shown promise in certain severe, hard-to-treat cases.

The drawback of these procedures is the expense. In many cases, they are not covered by medical insurance. The out-of-pocket cost can make these treatments out of reach for some.

There is also a time investment involved because, with both procedures, you will need a series of treatments done in order to see any type of result.

Both procedures can cause hyperpigmentation (skin darkening) or hypopigmentation (skin lightening), especially for those with medium to dark skin tones.

Your healthcare provider can tell you if these procedures are appropriate for you.

Antibiotics

Antibiotics are prescribed on an as-needed basis to help clear up any infection that has taken hold. Signs of infection include increased swelling, pain, warmth, and drainage of pus.

Antibiotics don't treat the underlying cause of pseudofolliculitis, though, so these can't be used as the sole treatment. Instead, they are used in conjunction with other treatments.

Prognosis

The prognosis for PFB is good, although you may end up with some residual hyperpigmentation or scarring.

There is no cure for pseudofolliculitis, so you will always be prone to developing ingrown hairs. It requires lifelong management to keep this skin condition at bay.

Coping

Having pseudofolliculitis barbae can be embarrassing as well as uncomfortable. Because it most often appears on the face, it feels so "front and center." Many people with PFB say they often feel embarrassed or ashamed because of the condition. It can affect self-esteem and self-confidence.

The most important thing you can do if you have this condition is to start treatment. There are many different options and, in most cases, pseudofolliculitis barbae can be considerably improved within just a few months with careful management.

In the meantime, if you desire, a tinted moisturizer, concealer, or cosmetic foundation can help tone down redness and help camouflage discoloration while you're waiting for treatments to work.

Summary

Pseudofolliculitis barbae, more commonly known as ingrown hairs, is a skin condition that occurs when facial hair (and sometimes pubic hair or underarm hair) grows sideways into the skin rather than directly up and out of the hair follicle.

PFB can cause stinging and burning, especially while shaving. Avoiding shaving altogether is the best way to prevent PFB. When this is not feasible, however, various drug treatments and procedures may be effective.