Medical article on PFB

A patient with moderate razor bumps finds improvement with

  1. a single-blade razor 1x a day

  2. topical prescription Benzacllin gel (benzoyl peroxide/clindamycin) 2x a day

  3. topical prescription Vaniqa cream (eflornithine hydrochloride) 2x a day

This is similar to options other consumers have recommended on the forums.

Pseudofolliculitis Barbae

Posted 06/07/2004

N0ah S. Scheinfe1d, MD, JD

25-year-old African-American man presented with a 7-year history of red-brown papules in his beard area. The papules had a rubbery texture and surrounded hair follicles. He had not tried any treatment for these papules but noted that they seemed to be less irritated when he did not shave. Based on these findings he was diagnosed with pseudofolliculitis barbae.


Papules, pustules, and round keloids that occur in the beard areas are known as pseudofolliculitis barbae (PFB) or shaving bumps. They are most common in African-American men (prevalence 10%-80%) but also occur in white men and in hirsute women who pluck facial hairs. Sarcoidosis and cutaneous fungal infections can mimic PFB, but the pathology of PFB involves a foreign body inflammatory reaction and the secondary infection that occurs when curved hairs grow back into the skin. In other words, a triad underlines PFB: ingrown curly hair, secondary infection, and secondary inflammation. Once PFB occurs it tends to worsen if untreated, leading to brown blotchy pigmentation, scarring, and persistent follicular infection. Letting the beard grow for 30 days to eliminate ingrown hairs can be helpful in ameliorating this condition but is sometime not effective or feasible, such as for persons in the US armed forces, for example, because facial hair is not permitted.


Treatment modalities for PFB are listed in Table 1. The use of the proper razor and shaving technique is helpful in ameliorating PFB. Use of single-edged, foil-guarded safety razors, in particular the Bump Fighter Razor (Shenandoah Supply, Staunton, VA) decreases skin trauma and the development of PFB. Specifically, when 30% of the blade is covered by foil, trauma is minimized. Double- or tri-ple-blade razors shave too closely and should not be used. Electric razors can be used if the razor foil is kept slightly above the skin’s surface and moved slowly; the closest shave settings should not be used. Electric clippers, which leave 1 to 2 mm of stubble (5 o’clock shadow), can be used but many patients find the presence of stubble on the face unacceptable cosmetically. Only a single method of shaving should be utilized. Cleaning the face before shaving removes oil and causes hairs to become more erect, making them easier to cut. Moisturizing shaving foam can be helpful, as well. If changes in shaving technique are not effective, it is sometimes helpful to let the beard grow for 30 days to eliminate ingrown hairs. It may also be helpful to manually extract ingrown hairs.

The original treatment for PFB diminished the presence of ingrown curly hairs with the use of depilatory creams. Mechanistically, depilatory creams break hair’s disulfide bonds, resulting in the hair being broken off bluntly at the follicular opening. Barium sulfide powder of about 2% strength is mixed with water to make a depilatory paste that is placed on the beard area and removed after 3-5 minutes. Calcium thioglycolate depila-tory – which has a strong odor and causes allergies – comes as a powder, lotion, cream, or paste that is placed on the face for 10-15 minutes; chemical burns result if left on too long. These depilatories cause irritation and are currently disfavored.

A variety of cosmetically acceptable and well tolerated topical and oral agents can be used to treat the infectious and inflammatory parts of the PFB etiologic triad. [1] Topical retinoids such as adapalene and tretinoin are useful. Benzoyl peroxide and antibiotics such as erythromycin or clindamycin and combinations thereof are very useful first-line treatments. Injectable corticosteroids (triamcinolone 2 mg/cc) can be used to soften papules and decrease inflammation but, because of side effects (cutaneous atrophy and hypopigmentation), are a temporary treatment. Aftershave gels containing benzoyl peroxide or glycolic acid can be useful.

Oral antibiotics can be useful to counteract both an anti-infectious and anti-inflam-matory agents. Tetracycline is a common choice for a systemic antibiotic. Similar to a standard acne regimen, a dose of 500 mg b.i.d. used initially for 1-3 months is often effective. Doxycycline 50-100 mg b.i.d. and minocycline 50-100 mg b.i.d. can be used as well and are probably more effective.

Two recent treatments, both dealing with the hair part of the PFB triad, are especially promising in the treatment of PFB: eflornithine hydrochloride cream and laser hair removal. Eflornithine hydrochloride 13.9% topical cream irreversibly inhibits ornithine decarboxylase, an enzyme that catalyzes the rate-limiting step for follicular polyamine synthesis that is necessary for hair growth. It has been approved for the treatment of hirsutism. In clinical trials, eflornithine cream slowed the growth of unwanted facial hair in up to 60% of women. Improvement occurs gradually over a period of 4-8 weeks or longer. Reported adverse reactions consisted of minor skin irritation. Laser hair removal is very promising in the treatment of PFB. Long-pulse neodymium: YAG laser, [2] long-pulse alexandrite laser, and the diode laser [3] have been used with very good effect in patients with PFB; however, multiple treatments are required and treatments can be expensive.


This patient began to use a single-blade razor and was treated with a topical gel combining benzoyl peroxide and clindamycin q.d. and eflornithine hydrochloride 13.9% topical cream The quantity of papules decreased and the papules became flatter (Figure 1). Proper shaving technique and topical treatments are effective modalities for treating mild and moderate PFB.

Figure 1. (click image to zoom) Sparse brown-red papules of pseudofolliculitis barbae effectively treated with a topical gel combining benzoyl peroxide and clindamycin once a day and eflornithine hydrochloride 13.9% topical cream twice a day

SKINmed 3(3):165-166, 2004. © 2004 Le Jacq Communications, Inc.

Only one thing about this that bothered me. Last I checked, topical prescription Benzacllin gel is very expensive…

I don’t suppose you could supply the photos with the article??

Photo is a pretty standard case of serious PFB. No after photos.

Other topicals
Benzoyl peroxide
Benzoyl peroxide + clindamycin
Benzoyl peroxide + erythromycin
Glycolic acid*
Chemical depilatories*


Shaving measure
Unhindered beard growth (30 days)
Razor shaving technique*
Hair clippers
Hair extraction*

Diode (810 nm)*
Long-pulse Nd:YAG laser (1064 nm)*
Long-pulse alexandrite laser*

  • extra caution must be used with these options.