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Clinical Quiz Answer

Facial Lesions on a College Basketball Player

Jeff Leggit, MD


The patient's lesions (figure 2) reveal erythematous papules and pustules, some of which have a hair follicle either erupting from them or have hair growing into the lesions. Hypertrophic skin changes reveal a chronic process with scarring. Such lesions are consistent with a diagnosis of pseudofolliculitis barbae (PFB).


PFB is a frequently encountered dermatologic disorder seen among athletes. It is also called chronic sycosis barbae, pili incarnati, folliculitis barbae traumatica, and, more commonly, razor bumps. The estimated prevalence of PFB comes from military studies and ranges from 50% to 80% in African-Americans and from 2% to 10% in Caucasians (1).

Pathophysiology and clinical presentation. PFB is a mechanical disorder best described as a foreign-body reaction to an ingrown hair. This disease occurs in populations that have tightly curled, spiral hair or in individuals who pluck their hair and damage follicles. PFB is most common on the neck, but it can occur anywhere the hair shaft becomes ingrown (eg, scalp, axilla, pubic area, and legs). The hair shaft may either erupt from the skin to curve back and reenter the skin, or it may curve while inside the follicle and grow through the follicular wall. When the hair shaft penetrates the wall, it becomes a pseudofollicle (2).

PFB produces tender, erythematous papules or pustules at pseudofollicular sites. These lesions may become secondarily infected, and in patients predisposed to forming keloids, a hypertrophic scar at the pseudofollicular area may be noticed. The differential diagnosis includes primary folliculitis, acne, and impetigo.

Treatment options. Because PFB is a mechanical problem, removing the offending agent is the definitive treatment. This can be accomplished passively by letting the tension of the growing hair remove itself from the pseudofollicle, which takes approximately 3 to 4 weeks. A more active approach is to dislodge each hair shaft from its pseudofollicle with a small-gauge needle. The active approach becomes impractical with widespread disease. Shaving must be temporarily discontinued until all pseudofollicles are resolved and the inflammation has been controlled. If secondary infection is suspected, an antistaphylococcal antibiotic (either topical antibiotics such as mupirocin calcium or dicloxacillin, or systemic agents such as cephalexin) should be used. If a lesion is particularly inflamed, an intralesional steroid injection with 2.5 to 10 mg/mL of triamcinolone diacetate can provide rapid pain relief and resolution (3).

Patients should not resume shaving until the lesions resolve. Once erythema and tenderness have resolved, patients must avoid close shaving and sharply angulated hair tips. This can be accomplished by hydrating and softening the beard with soap and warm water prior to shaving. A double-edged razor and a highly lubricating shaving gel should also be used. Another option is to use electric razors or clippers that are specially designed for use on this hair type. Shaving should be done in the direction of the hair growth, without stretching the skin, in single long strokes (3).

If shaving must be done regularly, several adjunct treatments are available. Daily application of 8% buffered glycolic acid either once or twice a day can be very helpful (4). The use of daily tretinoin or benzoyl peroxide is another alternative.

Another option is to remove the hair completely with chemical depilatories. The most common agents are over-the-counter products that contain either barium sulfide (eg, Magic Cream Shave, Carson Products, Savannah, Georgia) or calcium thioglycolate (eg, Palmer's No Blade, E.T. Browne Drug Co, Englewood Cliffs, New Jersey, or Surgi-Cream, Los Angeles).These agents work by reducing the sulfide bonds in the cortex of the hair shaft. The hair becomes weak and is wiped off when the chemical is removed (5). Depilatories are irritating, however, and can only be used once or twice a week. Recently, a surgical approach with a laser has been introduced, but patients should discuss its use with an experienced dermatologist (6). If all these endeavors fail, then shaving should be discontinued permanently.

There is no reason to restrict competition because of PFB since it is not contagious. If secondary infection is present, however, the patient should be on antibiotics for at least 72 hours or have no new lesions within the last 48 hours, according to National Collegiate Athletic Association guidelines (6).


  1. Dambro MR (ed): Griffith's 5-Minute Clinical Consult, ed 9. Baltimore, Lippincott Williams and Wilkins, 2021, p 886
  2. Brown LA Jr: Pathogenesis and treatment of pseudofolliculitis barbae. Cutis 120213;32(4):373-375
  3. Habif TP: Clinical Dermatology: A Color Guide to Diagnosis and Therapy, ed 3. St Louis, Mosby-Yearbook, 1996, pp 248-250
  4. Perricone NV: Treatment of pseudofolliculitis barbae with topical glycolic acid: a report of two studies. Cutis 1993;52(4):232-235
  5. Dunn JF Jr: Pseudofolliculitis barbae. Am Fam Physician 120218;38(3):169-174
  6. Crowe MA, Sorensen GW: Dermatologic problems in athletes, in Lillegard WA, Butcher JD, Rucker KS (eds): Handbook of Sports Medicine: A Symptom-Oriented Approach, ed 2. Boston, Butterworth-Heinemann, 1999, pp 367-380

The opinions or assertions presented here are the private views of the author and are not to be construed as official or reflecting on the US Department of the Army or Department of Defense.

Dr Leggit is a family physician with a certificate of added qualifications in primary care sports medicine at Darnall Army Community Hospital at Fort Hood in Harker Heights, Texas. Address correspondence to Jeff Leggit, MD, 2203 Delaware Dr, Harker Heights, TX 76548; e-mail to [email protected].