Wednesday, September 26, 2012

Pseudofolliculitis Barbare

Abstract:  24 year old man who has been struggling with pseudofolliculitis barbare (PFB) for 5 years. The following is adapted from notes the patient sent us and is presented here with his consent:

HPI: This type II skin, 24 yo man has been plagued with PFB for 5 years. At age 19 he was treated for one year with minocyclin which he accepted with no noticeable side effects for the first 4 months until he believed his teeth were developing a a gray tinge. During treatment, the sites inflammation diminished but ingrown hairs were still a problem despite not shaving.
For the past year, he has had no treatment other than washing his face daily with oil free "deep action exfoliating scrub" from and moisturizing with Pond's Dry skin cream. He has also been plucking ingrown hairs with tweezers. When cut he uses a topical "triple antibiotic ointment to prevent secondary infection. He has encountered many "hair whorls" which have grown completely under the skin. These hair whorls present as a hard lump with a darker tint under his type II skin. He has been able to remove the hairs which range in size from a half inch to an inch and a half with tweezers.
The ingrown hairs predominate on his jaw line and the hair whorls solely occur under his ear lobe (along his jaw line). The left side of his face is noticeably more affected than his right side. He attributes this to a nervous habit of his in which he scratches and pulls out hairs on his face in the affected region while he is working.

On Exam: He presents with numerous ingrown hairs on his right and left jaw line and in the submental area. The ingrown neck hairs grow about 2 mm in length before growing back into the skin. He also has ingrown hairs that have not surfaced and instead are growing shallowly underneath the surface of the skin. Pustules develop at the sites of the ingrown hairs (both the hairs that have not been able to grow out of the skin and the hairs that have grown back into the skin). 

Clinical Photo (taken by patient)
 Lab and Pathology: Not applicable

Diagnosis: Pseudofolliculitis barbare with pili incarnati

Questions:  Have you found a therapy that is successful in these patients?  Antibiotics?  Topicals? IPL or Alexandrite laser?  Other?

1.  Cook-Bolden FE, Barba A, Halder R, Taylor S . Twice-daily applications of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae.  Cutis. 2004 Jun;73(6 Suppl):18-24.
Abstract: Pseudofolliculitis barbae (PFB) is an inflammatory disorder characterized by the formation of papules, pustules, and hyperpigmentation as a result of ingrown hairs. It is estimated that PFB affects 45% to 83% of black men who shave regularly. In this multicenter, double-blind pilot study, men with 16 to 100 combined papules and pustules on the face and neck were randomized to receive twice-daily benzoyl peroxide 5%/ clindamycin 1% (BP/C) gel (BenzaClin)(n = 47) or vehicle (n = 41) for 10 weeks. Sixty-eight (77.3%) of the participants were black. All patients were required to shave at least twice a week and to use a standardized shaving regimen throughout the study. Clinical evaluations were performed at 2-week intervals. The primary efficacy parameter was the percentage change from baseline in lesion counts. At weeks 2, 4, and 6, mean percentage reductions from baseline in combined papule and pustule counts were significantly greater with BP/C gel compared with vehicle (P < or = .029). Treatment differences in favor of active therapy were more pronounced in the subpopulations of black patients, with least squares mean percentage reductions in papule and pustule counts ranging from 38.2% at week 2 to 63.9% at week 10. Study medication was well tolerated. These positive findings warrant further investigation of BP/C gel in the treatment of patients with PFB.

Existing remedies for controlling pseudofolliculitis barbae (PFB) are sometimes helpful; however the positive effects are often short lived. The only definitive cure for PFB is permanent removal of the hair follicle.
Our aim was to compare the efficacy of the Alexandrite laser with the intense pulsed light system in the treatment of PFB and to follow up the recurrence.
Twenty male patients seeking laser hair removal for the treatment of PFB were enrolled in this study. One half of the face was treated with the long-pulse Alexandrite laser and the other half was treated with the IPL system randomly. The treatment outcome and any complications were observed and followed up for one year.
All patients exhibited a statistically significant decrease in the numbers of papules. Our results showed that the Alexandrite-treated side needed seven sessions to reach about 80% improvement, while the IPL-treated side needed 10-12 sessions to reach about 50% improvement. During the one year follow up period, the Alexandrite-treated side showed recurrence in very minimal areas, while the IPL-treated side showed recurrence in bigger areas.
Our results showed that both systems might improve PFB but Alexandrite laser was more effective at reducing PFB than IPL.

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