Pearls of Wisdom: Treating Pseudofolliculitis Barbae
Adam, a 20-year-old black male, visits your office for his yearly influenza vaccine when you notice a prominent rash on his face and neck.
He tells you that he recently joined the Armed Services and needs to shave his beard frequently per regulations. In the past, he simply ‘trimmed’ his beard, and never encountered similar skin irritation. It is only since the requirement for a close shave in the last 6 months that he has experienced the sensitive bumps on his face and neck.
His history and physical examination are consistent with a diagnosis of pseudofolliculitis barbae. What would be an appropriate therapeutic consideration?
A. Reassure him that pseudofolliculitis is a self-limited condition, and will disappear after about 12 months.
B. Apply topical steroid daily after shaving to reduce inflammation.
C. Apply eflornithine cream twice daily.
D. Switch to a soy-based shaving cream.
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
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Answer: Apply eflornithine cream twice daily.
Pseudofolliculitis barbae (PSB)—also known as razor bumps—is a disorder that is most commonly seen in African Americans, but it can affect persons of any ethnicity.
Pathophysiology
In cases of PSB, after the coarse hairs on the face and neck are cut, they may recurve towards the skin. The sharp edges of recently cut hair inflict microtrauma to the skin, resulting in a small area of local inflammation. African Americans are more commonly afflicted with PSB because of the coarseness of their facial hair.
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Symptoms
The symptoms of PSB may range from a nuisance to severely problematic. They usually do not begin to become problematic until widespread repetitive shaving occurs, and although cutaneous granuloma-like nodules that have already formed may or may not regress when shaving is discontinued, new lesions stop occurring with shaving cessation or other effective treatments.
The Research
In the textbook, Clinical Dermatology 4th Edition, PSB is reported to be 10 to 30 times more common in African Americans, and is treated by simply stopping shaving (when not occupationally necessary), dislodging hair with a needle, or through the use of depilatories (eg, barium sulfide or calcium thioglycolate) that reduce sulfide bonds in hair shafts, leading to a soft fluffy hair tip, which is less likely to irritate or puncture skin.1
Eflornithine inhibits the enzyme ornithine decarboxylase in human skin, which reduces the rate of cell division and synthesis in hairs.
Eflornithine is FDA approved for the reduction of unwanted facial hair in women.
However, off-label use of eflornithine 13.9% cream has been tested for the treatment of PSB in men.2
Eflornithine for Pseudofolliculitis2
The Results
In a 10-week clinical trial of eflornithine applied twice daily for 16 weeks, men with PSB demonstrated a reduction of at least 1 point on a PSB severity. Clinical trials in women for unwanted facial hair show some degree of efficacy in multiple ethnicities, although results were best in Caucasians.
Patient-Practitioner Interaction
In this case, the young man became quite emotional at the mention of his skin condition and mentioned that he would not have mention it at all because he was embarrassed by it. In the same breath, however, he says he is glad that you brought it up so that he can talk to someone about it. As practitioners, the decision to bring up a noticeable condition that were not indicated as part of the reason for an office visit is sometimes difficult.
A reasonable approach might be saying “Allan, I know that you’re here just for a flu shot but I noted you have a bit of a rash on your face. Is this something that bothers you or that you’d like to talk about today? I think there are some things that could make it a lot better if it’s a problem to you.”
The advantage of this approach is that it broaches the topic without magnifying the issue it leaves the decision about whether to address it to the patient and informs him that a rationale for bringing it up in the first place is that helpful treatment is available.
Sometimes, the patient is just waiting for the clinician to get the conversation started, and they are grateful to discuss the issue. Other times, they are not bothered and will decline your offer for intervention.
In any case, at least the patient knows that if they desire to consider treatment for the disorder, you have noted it and indicated that treatment is available.
What’s the “Take Home”?
PSB tends to be underplayed by sufferers, who may think that it is something they just have to live with, that it is not an ‘important’ medical problem, or may hesitate due to simple embarrassment. Although the condition usually resolves or improves upon shaving cessation, that may not be an option. In those cases, eflornithine may produce meaningful improvements for afflicted men.
References:
1. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. St Louis, MI: Mosby Publishers; 1996.
2. Tucker ME. Eflornithine cream clears razor bumps. Fam Pract News. 2001;34(18):15.