Folliculitis Barbae
Introduction
According to histological definitions, folliculitis barbae can be described as the “presence of inflammatory cells within the wall and ostia of the hair follicle, creating a follicular-based pustule” (Satter, 2012). There is a variation in the tangible kind of inflammatory cells as their nature is mainly dependent on folliculitis’ etiology. The inflammation has different effects. It may limit itself to the external phase of the follicle with the involvement of the infundibulum at a primary level. On the other hand, there may be an inflammatory effect on both aspects of the follicle i.e. external and internal (Satter, 2012).
In contrast, Perifolliculitis barbae is “the presence of inflammatory cells in the perifollicular tissues and can involve the adjacent reticular dermis” (Satter, 2012). Both the mentioned types of folliculitis have independent manifestations. However, they may also occur together as a consequence of follicular disorder, disturbance and irritation (Satter, 2012).
Folliculitis Barbae
Folliculitis Barbae is the condition in which the formation of hair occurs within the skin as hair follicles that are minute hairy structures. The word folliculitis is used to depict the inflammation of these tiny hairy structures. Even though such kind of inflammation can affect any part of the skin, folliculitis barbae is the term that specifically refers to the inflammation of the hair follicles that affect the area where beard grows.
Causes
In general, Staphylococcus aureus infection is the major cause of this condition. The mentioned infection is recognized as mainly affecting the skin of a person. Though folliculitis barbae may transpire in a bearded area that is not shaved; men who shave are mostly affected by this condition. These bacteria unnoticeably line inside the nasal area due to which there are higher chances of reinfection. In addition, shaving equipment containing contaminations also have these bacteria and when an individual uses improper and unclean equipment for shaving, reinfection may take place. In some cases, there is no involvement of S.aureus and the involvement of harmless skin bacteria results in folliculitis barbae.
More often than not, the upper part of the hair follicle is affected by the infection on the external surface of the skin. In a number of cases, on the other hand, the infection is more deep-rooted. The follicles may appear red and feel itchy due to the setting up of a constant inflammatory reaction by the immune system. Such a condition has been given the name of sycosis barbae. At seldom occasions, scarring is caused by such a condition. It is exceedingly important to note here that the infections that are caused by fungi or herpes virus cannot be considered as folliculitis barbae. It is also imperative to note that folliculitis barbae is not hereditary.
Symptoms
Folliculitis barbae is characterized by itchiness and tenderness of the beard area. The use of razor may cut the spots that have a severe effect on the beard area. Bleeding may result as a consequence. Folliculitis barbae may infect the hair follicles in the beard area by causing a small red inflammation and enlargement to appear at the root of the skin from where the hair grows up.This swelling is frequently observed to come together with a septic spot with a yellow-head. Thus, folliculitis barbae usually affects a lot of hair follicles. In case of the development of an inflammatory reaction, an extension can be seen from where the follicles appear red. These follicles are joined up often that cause itchiness and irritation.
Diagnosis
For diagnosis of folliculitis barbae, the doctors take a pus sample and then test it for infection. The sample results then makes it easier for them to recommend the antibiotics that may help the individual. In case when there is no quick clearance of the folliculitis, swabs and scrubbing down of the infected area is done and sometimes noses of the patient and family members are also checked to check whether any bacteria is the real cause of the infection. The skin is also closely examined to find out whether the spots indicate the occurrence of folliculitis barbae or pseudofolliculitis. This close examination of the skin is important as both conditions can affect the skin at the same time.
Treatment
Every now and then, this condition can be cured. However, the curing varies from person to person as every individual has a distinctive skin type. In some individuals, curing shows less response. But treatment in a timely and appropriate manner can help this condition to go away. One of the most important things to mention here is that the scars which develop as a result of this condition are life-long. The skin appearance improves usually over a period of time but the scars do not vanish. In many cases where there is a straightforward infection, a proper antibiotic course is enough for the skin to response quickly. Such antibiotics are available in the form of creams and oral medications. In case of a reinfection due to nasal bacteria, physicians usually recommend the application of an antibiotic ointment inside the nostrils. When there is a development of chronic inflammation, the patient is recommended to use a mild steroid cream. In cases that are more difficult to treat, the suggestions given by the doctors include the use of an antibiotic that may help to get rid away of both anti-inflammatory and antibacterial effects.
If an individual is persistently affected by the folliculitis barbae, he/she is advised to take necessary steps to lessen the contamination from equipment used for shaving. It is suggested that metal parts of the shaving equipment must be scalded on a regular basis with boiling water. If a person uses razor or electric shaver, the plastic parts that may infect the skin must be cleaned in a careful manner after every time they are used. Alcoholic antiseptic solutions must also be used to soak the shaving equipment. Sometimes, it is better to use an antiseptic lotion instead of using shaving soap or foams to avoid any infection of the skin.
Pseudofolliculitis barbae
Pseudofolliculitis barbae is an irritating and irking chronic condition that can develop as a result of attempts to get rid of hair from the bearded area (Quarles, Brody, Johnson, Badreshia, Vause, Brauner & Callendar, 2007). It is quite difficult to determine the occurrence of this disorder. However, studies regarding the disorder have reported that this disfiguring condition affects more or less one individual out of every five Caucasian individuals. It is also revealed from the studies that it occurs very commonly in black persons. It is not only a condition that affects men but women can also get this disorder no matter from which race they belong. The inflammatory papules and pustules appearance is the main clinical characteristic of this disorder. This condition is a direct result of the inappropriate shaving techniques causing “ingrown hairs through both transfollicular and extrafollicular mechanisms” (Halder, 1988). Same treatment as that of acne is adopted, once the pseudofolliculitis barbae is established. It can also be treated by avoiding shaving along with the medication and in extreme cases, diode lasers can be used (Yamauchi, Kelly & Lask, 1999). The long-term result is dependent entirely on prevention through a correct shaving technique. In severe cases of pseudofolliculitis, when definitive solution is sought, the choice of treatment is photodepilation (Ribera, Fernández-Chico & Casals, 2010). As the main factor that is responsible in the condition’s pathogenesis is hair, a definite treatment is the elimination of hair.
Epidemiology
In general, men with curly, coarse hair are affected by Pseudofolliculitis barbae. It is reported that 45-83% African-American men suffer from this condition and it has turned out to be a leading concern in black US army recruits. A survey carried out at the Skin of Color Center concerning 71 patients with PFB (41 females and 30 males) confirmed an average age of beginning to be 22 years (Coley & Alexis, 2009).
Pathogenesis
An ingrown hair shaft results in this chronic-body reaction that is called Pseudofolliculitis barbae. It is thought that a curved hair follicle which is present in African descent individuals, predispose cut hair and reenter the dermis which leads to this reaction. There are two mechanisms which are so far described i.e. extrafollicular penetration and transfollicular penetration. In the extrafollicular penetration, the very sharp edge of the hair that was shaved follows its natural curvature to the surface of the skin and re-penetrates in a retrograde fashion. Transfollicular penetration is the piercing of the follicular wall by the shaft of the hair recently cut, which as a consequence enters the dermis without ever exiting the epidermis (Coley & Alexis, 2009).
Pulling of the skin rigidly while shaving boosts the danger of transfollicular penetration by allowing recently cut hair to retract underneath the skin’s exterior. Transfollicular penetration can also result for ingrown hair seen with waxing or plucking, which leaves hair fragments inside the skin. In both of the types of re-entry, the shaft of the hair penetrates the dermis thus triggering the foreign-body inflammatory response that may result in the formation of pustules and papules. A single nucleotide polymorphism has been identified by medical scientists which imparts the partial genetic risk of the development of the PFB (Coley & Alexis, 2009).
Clinical Features
The hallmarks of PFB are follicular and perifollicular papules and pustules in the beard area. Post-inflammatory hyper-pigmentation (PIH) is also a commonly linked feature which is reported in a majority of cases. Commonly affected area is the bearded area of the face, which may or may not include the anterior neckline, mandibular areas, chin and cheeks. In some severe cases, hypertrophic scars are also seen. Embedded hair can also be seen with the papules in severe cases. After growing approximately 1cm in length, this hair will spontaneously release through the loop mechanism. Depressed patterns can be present due to the parallel hair growth. Some patients may feel itching and pain. In the secondary infection cases, cultures of pustules are generally sterile (Coley & Alexis, 2009).
The presence of PFB lesions can be distressing to patients. Considerable anxiety in appearance can also be present. PFB majorly contributed to racial tension among African-American soldiers in the US army due to the military grooming code which requires a clean-shaven face. For majority of these men, compliance with the code means suffering with PFB (Coley & Alexis, 2009). The Folliculitis Barbae inflammatory response is dependent on “the shape of the hair follicle, hair cuticle, and the direction of hair growth” (Perry, Cook-Bolden, Rahman, Jones & Taylor, 2002) as every one of them has a certain role. People with this condition tend to suffer emotional distress as it causes as unattractive and ugly cosmetic appearance.
Treatment
Hair Removal
This condition can be prevented by allowing the beard to grow for a month which can result in spontaneous resolution of most PFB papules cases in Folliculitis Barbae. However, in some cases, the growth of the beard for a full month is not possible. Personal preferences and clean-shaven face appearance may act as the limiting factors. In such cases, alternative hair removal and counseling about proper shaving techniques become mandatory in order to control and reduce the flares (Coley & Alexis, 2009).
Most men can easily control the condition with maintaining an optimal beard length of 0.5 to 1 mm. The hair can be cut through the electronic clippers as they allow the user to set the length of the hair and cut the rest. By tradition, most of the authorities suggest the use of a single blade razor to avoid the PFB. A recommended razor is Bump Fighter (American Safety Razor Company, VA, USA) as its blade is coated with the polymer and a foil guard that keeps the edge of the blade slightly off the skin and it prevents the trimming of the hair too close from the skin. In a study, this razor has been shown to reduce the number of PFB lesions. According to a recent study in this field, no increase was observed in the number of PFB lesions in men who used Gillette five blade razor daily for 8 weeks. Random, blinded clinical research comparing the use of single-edged and multi-edged razors, shaving techniques and frequencies are needed in order to explain optimal shaving recommendations for PFB (Coley & Alexis, 2009).
Medical Management
Medical Management is another treatment option that includes a combination of therapies that are used to treat PFB, topical antibiotics, low-potency corticosteroids and use of topical retinoid. Topical retinoid helps to alleviate the hyperkeratosis associated with the repetition of the follicular epithelium as well as PIH. In place of commercial aftershave products, low to mid potency topical corticosteroids can be used. Prior to shaving, benzoyl peroxide wash can also be helpful. Antimicrobials such as Benzoyl peroxide and erythromycin can be used to reduce the colonization of bacteria which can result inflammation and result to secondary infections. PFB-associated PIH can be treated successfully with bleaching agents such as hydroquinone and kojic acid etc (Coley & Alexis, 2009).
Chemical Depilatories
Chemical Depilatories can be used as an alternative too by men who are burdened with this condition as it is a useful hair-removal option. Chemical depilatories are an alternative to shaving that has been used from several years as an alternate for shaving. Barium sulfide or calcium thioglycolate are the substances that are present in cream and lotion forms and they work well in weakening the disulfide bonds in keratin. By the use of these substances in Folliculitis Barbae, the hair can be easily removed from the skin surface with a blunt instrument for the removal of hair (Bridgeman-Shah, 2004). It makes the transfollicular and extrafollicular penetration very less likely to happen. Irritant and allergic reactions may appear with the use of these chemicals resulting in PIH in case of prolonged exposure. A test patch to determine irritation potential is recommended before taking the treatment (Coley & Alexis, 2009).
Eflornithine Hydrochloride
US FDA approved a cream named as Eflornithine hydrochloride for the treatment of unwanted facial hair in women (Coquilla & Lewis, 1995). This cream irreversibly slows down the enzyme in hair cell division, which ultimately results in less hair growth rate in the area applied. Although, this cream is not indicated for the use of PFB, it has been found to be used for the purpose of decreasing the hair growth in men suffering from PFB. All the considerations need to be discussed with the patient prior to adoption to avoid the unrealistic expectations from the treatment (Coley & Alexis, 2009).
Epilating
Epilating in the form of electrolysis is one of the forms of permanent hair removals which can be considered for limited areas. This process is potentially painful and costly. This process is not of more success in African-American people as it is difficult to ablate the curved and distorted hair follicle. A merged technique of electrolysis by means of galvanic and thermolysis currents have been effective. In fact, electrolysis can actually exacerbate PFB and promotes transfollicular penetration and therefore is generally not recommended as a cure treatment (Coley & Alexis, 2009).
Chemical peels
Chemical peels is an another option to treat Folliculitis barbae as superficial chemical peels are safe and effective in addition to therapy for PFB. It has been proposed that glycolic acid have properties to reduce sulfhydryl bonds and in addition to that its exfoliating effects are good. The reduced bonds of sulfhydryl in the hair shaft can result in the growth of straighter hair and can potentially reduce the possibility for re-entry of the hair shaft in the epidermis. The peels of salicylic acid offer exfoliation and lightening in the cases complicated with PIH. Research showed reduced number of PFB lesions with both salicylic acid and glycolic acid peels (Coley & Alexis, 2009).
References
Bridgeman-Shah, S. (2004). The Medical and Surgical Therapy of Pseudofolliculitis Barbae. Dermatologic Therapy, 17(2), 158-163.
Coley, M. K., & Alexis, A. F. (2009). Dermatologic Conditions in Men of African Ancestry. Medscape Today. Retrieved August 12, 2013, from http://www.medscape.com/viewarticle/715199_2
Coquilla, B., & Lewis, C. (1995). Management of Pseudofolliculitis Barbae. Military Medicine, 160(5), 263-269.
Halder, R. (1988). Pseudofolliculitis Barbae and Related Disorders. Dermatologic Clinics, 6(3), 407-412.
Quarles, F., Brody, H., Johnson, B., Badreshia, S., Vause, S., Brauner, G., & Callendar, V. (2007). Pseudofolliculitis Barbae. Dermatologic Therapy, 20(3), 133-136.
Perry, P., Cook-Bolden, F., Rahman, Z., Jones, E., & Taylor, S. (2002). Defining Pseudofolliculitis Barbae in 2001: A Review of the Literature and Current Trends. I, 46(2 Suppl Understanding), S113-S119.
Ribera, M., Fernández-Chico, N., & Casals, M. (2010). [Pseudofolliculitis barbae]. Actas Dermo-Sifiliográficas, 101(9), 749-757.
Satter, E. K. (2012, July 10). Folliculitis .Medscape Reference: Drugs, Diseases and Procedures. Retrieved August 12, 2013, from emedicine.medscape.com/article/1070456-overview
Yamauchi, P., Kelly, A., & Lask, G. (1999). Treatment of Pseudofolliculitis Barbae with the Diode Laser. Journal Of Cutaneous Laser Therapy, 1(2), 109-111.