Pseudofolliculitis barbae (PFB) is a foreign body inflammatory reaction involving papules and pustules on the beard area—the lower face and neck—of men. Typically, there are groups of small red or pigmented bumps on the beard area that may flare with repeated shaving, and PFB tends to be worse with very curly or kinky hair.
Causes of PFB
There are two primary causes of PFB:
- Extrafollicular penetration occurs when the sharply pointed hair from a recent shave briefly surfaces from the skin and re-enters a short distance away (See Extrafollicular Exfoliation); and/or
- Transfollicular penetration occurs when methods of very close shaving result in a hair that is cut below the surface. These methods include pulling the skin taut while shaving, shaving against the grain, plucking hairs with tweezers, and using double- or triple-bladed razors. The close shave may result in a sharp tip below the skin surface, which is then more likely to pierce the follicular wall, causing PFB with transfollicular penetration.1, 2
Treatment for PFB
Treatment for this condition depends on its severity. Treatment specifications include shaving protocols, skin care ingredients and regimens, and prescriptive remedies. An effective starting point for treatment is to advise clients to let their beard grow for 30 days to eliminate ingrown hairs, if lifestyle and work environment allow for this. When they are ready to shave again, ask them to follow these specifications.
Shaving protocols for clients.
- Place a warm towel over the face for a few minutes before shaving in order to open the pores, or take a warm shower before shaving. This softens the skin and the hair. Use a moisturizing shaving lather that also has antibacterial properties and allow it to sit on the skin for 2–3 minutes before shaving. This will soften the beard and, once the hair is cut, will result in a more rounded tip to the hair, which is less likely to re-enter the skin.
- If using a razor, select a single-edged, foil-guarded or safety razor.3 Double- or triple-bladed razors shave too closely and should not be used. Razors that have about 30% of the blade guarded, which prevents the blade from shaving the hair too closely, are recommended and marketed specifically for PFB-sufferers.
- Make sure the razor is thoroughly rinsed free of shaving lather each time it is used. This will avoid putting hair stubble back onto the skin where it may cause bacteria or fungi to form.
- Shave in the direction of the follicle, not against it.
- Do not stretch the skin.
- Do not puncture or tweeze affected areas.
- Electric razors have acceptable results if used properly. The recommended technique with a three-head 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 should be kept off of the closest settings.
- Electric clippers are effective for resistant cases of PFB. With clippers, 1–2 mm stubble can be left on the face. The tendency to shave too closely is reduced with this method, making it more effective.
- Clean shaving devices with hydrogen peroxide.
- Only use clean towels to avoid the spread of bacteria or fungi.
Skin care ingredients and regimen
PFB creates an inflammatory environment that often includes bacteria, fungi and infection. Therefore, it is important to look for skin care ingredients that soothe, are anti-inflammatory, and include antifungal and antibacterial active ingredients. Identify quality, effective skin care products that achieve these outcomes. Clients’ regimens should include the following four steps.
- Clients should cleanse their skin daily in circular motions each morning and evening.
- Skin should be exfoliated to dislodge the impacted hair using products with the recommended ingredients; consider selling a gentle exfoliating brush in the retail area for use. Daily exfoliation is ideal for PFB environments. If clients use an exfoliating brush, they should clean the brush with an antibacterial wash or hydrogen peroxide regularly to eliminate bacteria.
- Apply a soothing gel immediately after shaving that is anti-inflammatory, and that addresses a wide variety of fungi and bacteria.
- Incorporate remedies for hyperpigmentation to avoid immediate and long-term discoloration. A sampling of ingredients to look for in skin care that address the symptoms of PFB include the following:
- Antifungal and antibacterial—bitter orange extract, yucca stem extract, tea tree oil and acnacidol;
- Soothing, anti-inflammatory and repair—prickly ash bark, calendula, allantoin, arnica, sodium hyaluronate;
- Exfoliating—alpha hydroxy acids and glycolic acids; and
- Post-inflammatory hyperpigmentation—niacinamide, Gigawhite and liposome vitamin C.
Drug remedies for severe PFB
As with any prescription or over-the-counter (OTC) drug, there may be negative side effects with use of the following drugs, and long-term use is not recommended. Although eradicating the symptoms of PFB through shaving protocols and effective skin care products and regimens is preferable, following are drugs that can be used to help treat severe PFB.
- Topically applied tretinoin has shown promise. 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.4, 5
- Mild topical corticosteroid creams reduce inflammation of papular lesions.4
- For severe cases of PFB with pustules and abscess formation, topical and oral antibiotics may be 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.6, 7
Products, services and home care
Although usually not regarded as a serious medical problem, PFB can be painful, embarrassing and cause cosmetic disfigurement. The papules can lead to scarring, post-inflammatory hyperpigmentation, secondary infection and keloid formation—an overgrowth of fibrous tissue or scars. By offering products and services to help your growing male clientele with PFB, and providing education for home care, you can become the go-to resource for clients suffering from this condition—and their friends.
- FN Quarles, H Brody, BA Johnson, et al., Pseudofolliculitis barbae, Dermatol Ther 20 3 133–136 (May/Jun 2007)
- C Kindred, CO Oresajo, M Yatskayer, RM Halder, Comparative evaluation of men’s depilatory composition versus razor in black men, Cutis 88 2 98–103 (Aug 2011)
- AM Alexander, Evaluation of a foil-guarded shaver in the management of pseudofolliculitis barbae, Cutis 27 5 534–537, 540–542 (May 1981)
- ND Childs, Tretinoin, hydrocortisone cream controls PFB, Skin and Allergy News 30 5 20 (1999)
- EV Ross, LM Cooke, AL Timko, et al., Treatment of PFB in skin types IV, V, and VI with a long-pulsed neodymium:yttrium aluminum garnet laser, J Am Acad Dermatol 47 2 263–270 (Aug 2002)
- AM Kligman and OH Mills, Pseudofolliculitis of the beard and topically applied tretinoin, Arch Dermatol 107 4 551–552 (Apr 1973)
- LA Brown, Pathogenesis and treatment of pseudofolliculitis barbe, Cutis 32 4 373–375 (Oct 1983)
- JJ Leyden, Topical treatment for the inflamed lesion in acne, rosacea and pseudofolliculitis barbae, Cutis 73 6 Suppl 4–5 (Jun 2004)
IM Freedberg, ed., Fitzpatrick’s Dermatology in General Medicine, 6th ed., McGraw-Hill, New York (2003)
JL Bolognia, ed., Dermatology, Mosby, New York (2003)
R Schulze, KJ Meehan, A Lopez, et al., Low-fluence 1,064-nm laser hair reduction for pseudofolliculitis barbae in skin types IV, V and VI, Dermatol Surg 35 1 98–107 (Jan 2009)
Holly Harmon is vice president of aesthetics and training for SkinPhD Cosmeceuticals. She is a dual-licensed esthetician and massage therapist, and has advanced medical esthetics training along with decades of experience working with many medical esthetic modalities and product formulations. Harmon can be reached at [email protected].