Pseudofolliculitis

What is pseudofolliculitis 

Pseudofollicultis is also known as razor/shaving bumps, “barber's itch”, scarring pseudofolliculitis of the beard, and folliculitis barbae traumatica.

Pseudofolliculitis is a recurring inflammatory reaction to hair follicles caught within the skin as they grow. It typically affects people with coarse curly hair. It is not usually caused by infection. 

Who is affected by pseudofolliculitis? 

Pseudofolliculitis most commonly affects men especially of African ancestry, and women (from all ethnic groups) who shave, pluck, or wax. It affects any site where coarse hairs are shaved/removed e.g. beard area, scalp, armpits, pubic area and legs. 

What does pseudofolliculitis look and feel like?

Multiple, firm, skin-coloured to red/dark bumps and pus filled spots. The spots are centred on hair follicles (hair growth sites) at any site of shaving or plucking. An itching or burning sensation can occur within 24-48 hours of shaving. 

What causes pseudofolliculitis? 

After close shaving, plucking or waxing, sharp hair ends below the skin surface (or just above the surface) grow from the curved hair follicle and project downwards into the lower layer of the skin (dermis). This sometimes leads to puncturing of the hair follicle, causing inflammation.

What are possible complications of pseudofolliculitis? 

These include:

• Post-inflammatory hyperpigmentation: the skin may appear darker where it has been inflamed
• Hypertrophic scarring and keloid formation (raised/thickened scars)
• Temporary or permanent hair loss
• Sycosis barbae – deep sinuses and abscesses may sometimes develop; they may require treatment with antibiotics and topical steroids

Your mental health

Pseudofolliculitis can have a significant psychological impact and may affect many areas of daily life including work. If there is a requirement to be clean shaven a GP letter may be needed to support not shaving.

Things you can do to help yourself  

Ideally stop shaving if possible and avoid waxing or plucking - the skin will often settle 4-6 weeks after stopping shaving. Once settled, resume shaving as follows:

• Prewash with an antimicrobial wash (e.g. benzoyl peroxide wash)
• Prepare skin with a warm moist flannel
• Carefully release visibly embedded hairs with a sterile needle or by brushing with a soft toothbrush; do not pluck them
• Use a lubricating shave cream or gel
• Ideally shave less often (not every day). Avoid close shaves. Men should aim for a beard with a hair length of 0.5-1mm, which can be achieved by using an electric/foil-guarded razor or adjustable clippers
• Shave each area of skin once only, in the direction of hair growth
• Avoid stretching or pulling the skin as the hair is then more likely to reenter the skin under the surface

Make an appointment at your GP surgery

If things are not improving, your primary care health professional may swab an active spot. You might be prescribed:

• A low strength topical steroid cream (e.g. 1% hydrocortisone ), or topical benzoyl peroxide +/- topical antibiotic cream to apply after shaving
• Oral antibiotics, often for 6-12 weeks
• A topical retinoid cream e.g. adapalene

Referral to a specialist 

Depending on the problems you are experiencing you could be referred either to a dermatologist or a GPwER/GPwSI (a GP who has been trained in relevant areas of dermatology). One of the most common reasons for referral is if you have developed thick scars, which can be injected with a steroid.

Alternative approaches to hair removal

None of the treatments listed below are permanent; if helpful, treatments need to be repeated. In most areas of the UK the following treatments are not available on the NHS:

• Eflornithine hydrochloride cream 13.9% (Vaniqa) results in decreased hair growth rate. It does not remove hair. It can be used in combination with any physical treatment
   
• Laser assisted hair removal reduces the density of hair growth. It works best for coarse dark hairs. Occasionally it can cause the surrounding skin to become lighter or darker
   
• Chemical hair removal. Care must be taken as irritation can cause inflammation related darkening of the skin (hyperpigmentation); this is more likely with longer contact times
   
• Electrolysis can exacerbate pseudofolliculitis; it may be helpful in some
   
• Superficial chemical peels with salicylic acid, glycolic acid and hydroquinone can be used to treat both pseudofolliculitis and post-inflammatory hyperpigmentation

Helping with other skin conditions

If you, a family member, or friend have an undiagnosed skin condition; or you want to learn more about how to treat skin conditions, please view our short video on how to get the best from this website.