Pseudofolliculitis barbae vs. folliculitis barbae

HairTell gets a lot of questions about pseudofolliculitis barbae, which means “FAKE inflammation of the beard.” Someone asked is there a real kind?

The answer is yes, there is folliculitis barbae. The difference between the two is the cause of the inflammation in the hair follicles.

Folliculitis barbae is caused by viral or bacterial infections, where pseudofolliculitis is caused by irritation from shaving.

Below are some recent clinical articles on causes of folliculitis barbae, but those looking to clear up razor bumps or PFB should read the article below:

HairTell Premium article on pseudofolliculitis barbae (PFB)

Clinical data on folliculitis barbae

[A case of Folliculitis barbae Candidomycetica]
Nippon Ishinkin Gakkai Zasshi. 2001;42(2):87-90.
[Article in Japanese]
Hattori A, Iida T, Yamaguchi Zi, Nishiyama C.
Department of Dermatology, Nihon University Nerima Hikarigaoka Hospital, 2-11-1 Hikarigaoka, Nerima-ku, Tokyo 179-0072.

A 71-year-old man was referred to our department on January 30, 1998 with hard red papules that had developed on the philtrum in mid-January. On January 2, the patient had received high-dose steroid therapy (pulse therapy) for cluster asthma attacks and antibiotics at the Department of Internal Medicine of our hospital. Infiltrative, protruding reddish plaques were observed on the philtrum, which contained a number of small pustules at sites corresponding to hair follicles. There was partial opacity and slight irregularity of the nail plates on the first and second toes of the right foot. Fungal elements were detected from a lesion on the mustache and the nail. Histological examination of the lesion on the philtrum revealed infiltration of inflammatory cells comprising neutrophils, lymphocytes, and macrophages around the hair follicles. Beard hair and nail cultures revealed Candida albicans A, indicating that the patient had candidal sycosis and candidal onychia. He was treated with oral fluconazole (100 mg/day). The lesion was clinically improved within 50-days. Recently, extensive use of steroids and antibiotics has produced an increase in reports of patients with Folliculitis barbae Candidomycetica. We believe that the present case was also induced by high-dose steroid therapy and antibiotics.

Publication Types:
Case Reports
Review of Reported Cases
PMID: 11331469

Hautarzt. 2004 Jan;55(1):74-6.

[Folliculitis barbae in herpes simplex infection]

[Article in German]

Lohrer R, Rubben A.

Klinik fur Dermatologie und Allergologie, Universitatsklinikum der RWTH Aachen, Aachen.

A 60-year-old male athlete developed a folliculitis in the beard region after several competitions. After identification of herpes simplex antigen within the lesions, systemic therapy with acyclovir led to rapid improvement. In folliculitis resistant to antibiotic and anti-inflammatory therapy, viral and mycotic infections as well as eosinophilic folliculitis should be considered as differential diagnostic possibilities.

Publication Types:
Case Reports

PMID: 14749868

J Dermatol. 2003 Dec;30(12):898-903.
Tinea barbae (tinea sycosis): experience with nine cases.

Bonifaz A, Ramirez-Tamayo T, Saul A.

Dermatology Service and Micology Department, General Hospital of Mexico, Dr. Balmis 148, col Doctores CP 06720, Mexico D.F., Mexico.

Tinea barbae is a rare dermatophytosis that affects the hair and hair follicles of the beard and mustache. This paper presents 9 cases of tinea barbae observed over an 18-year period of time and classified as follows: 1 was superficial and 8 were deep (6 folliculitis-like and 2 kerion-like). Most of the cases (4) were associated with topical steroid therapy, others with pet contact (3 cases) and one with diabetes. The causal agents isolated were: Trichophyton rubrum in 3; Microsporum canis in 3; Trichophyton mentagrophytes in 2; and Trichophyton tonsurans in one. The involvement of the hair was observed and classified in all cases. The trichophytin skin reaction was positive in all 9 patients. All the patients were treated with systemic antimycotics, 3 cases with griseofulvin, 1 with ketoconazole, 3 with itraconazole, and 2 with terbinafine. Clinical and mycologic cures were achieved at 6 to 8 weeks of treatment at the usual doses.

Publication Types:
Case Reports
PMID: 14739517

Dermatol Nurs. 2003 Dec;15(6):527-30, 534.
Difficulties in diagnosing and treating tinea in adults at the Department of Dermatology in Bialystok (Poland).

Krajewska-Kulak E, Niczyporuk W, Lukaszuk C, Bartoszewicz M, Roszkowska I, Edyta M.

Department of General Nursing, Mycological Laboratory, Medical University of Bialystok, Poland.

In the years 1981-2000, the department of dermatology at the Medical University of Bialystok, Poland, carried out a retrospective study of common difficulties in the diagnosis and treatment of tinea. The aim of this study was to assess the incidence of incorrect diagnosis and therapy of tinea and tinea incognito (TI) in the patients hospitalized at the institution over a 19-year period. Tinea was identified in 814 patients (4.3% of all patients). TI was diagnosed in 318 patients (39.1% of all patients with tinea). The most diagnostic-therapeutic problems were observed in the patients with tinea pedis, tinea cutis glabrae superficialis, intertrigo candidamycetica, tinea profunda cutis glabrae and tinea profunda barbae. The most common clinical isolates were T. rubrum, T. mentagrophytes, and Candida albicans. A high percentage of TI was present in comparison with all other tinea conditions.
PMID: 14735603

Mycoses. 2001;44(7-8):334-7.
Related Articles, Links

Case reports. Six cases of infection due to Trichophyton verrucosum.

Roman C, Massai L, Gianni C, Crosti C.

Dermatophyte infections due to Trichopkyton verrucosum are not frequent in Europe. Six cases observed in Italy in the period 1995-99 are reported. Two were cases of tinea barbae, two of tinea corporis and two of tinea capitis, one of which had been preceded by tinea faciei. In three cases the source of contagion was horses, in two it was cattle and in one case it was another person. The two cases of tinea barbae were initially interpreted and treated as bacterial infections, a diagnostic error reported with increasing frequency in the literature regarding dermatophytosis due to T. verrucosum.

Publication Types:
Case Reports
PMID: 11714072

J Eur Acad Dermatol Venereol. 2001 May;15(3):250-1.
Related Articles, Links

Tinea barbae associated with erythema nodosum in an immunocompetent man.

Foti C, Diaferio A, Daddabbo M, Angelini G.

Department of Internal Medicine, Immunology and Infectious Diseases, University of Bari, Italy.

We describe the case of a 45-year-old man with atopy who developed marked inflammatory lesions on the bearded area of the face caused by Tricophyton rubrum, an anthropophilic fungus not frequently correlated with kerion of the face. After starting therapy with griseofulvin, he developed typical lesions of erythema nodosum on both legs. We discuss how these lesions could be correlated with the kerion of the face.

Publication Types:
Case Reports
PMID: 11683291

Mycoses. 2002 Apr;45(3-4):101-4.
Dermatophytes and other fungi associated with skin mycoses in Tripoli, Libya.

Ellabib MS, Khalifa Z, Kavanagh K.

Department of Medical Microbiology, Medical College, Al-Fateh University, Tripoli, Libya.

This study sought to determine the prevalence of skin infections and their causative agents in the Libyan population. Samples were collected from 2224 patients attending the Dermatology Clinics of the Tripoli Medical Centre (TMC) between August 1997 and December 1999 and were submitted to a mycology laboratory for analysis. Diagnosis was confirmed by microscopic examination in 1180 cases (53.1%) and the causative agent was isolated and cultured in 1160 cases (52.2%). Dermatophytes, Malassezia furfur and Candida albicans were the most common etiological agents isolated. Tinea corporis accounted for 45.9% of cases (85% of cases occurred in children below 15 years of age). The frequency of the other clinical types in descending order was pityriasis versicolor 27.8% (322 cases), candidiosis 13.4% (156 cases), tinea pedis 8.1% (94 cases), tinea manuum 2.6% (30 cases) and tinea barbae 2.2% (26 cases). Trichophyton violaceum was the most common etiological agent, responsible for 44% (300 cases) of dermatophyte infections. Malassezia furfur was ranked the second most frequent causative agent being found in 27.8% of cases, followed by Trichophyton rubrum 13.8% (160 cases) and Candida albicans 10% (116 cases). Other species isolated included Microsporum canis 8.1% (94 cases), Epidermophyton floccosum 6.6% (76 cases) and Trichophyton mentagrophytes 3.1% (36 cases).
PMID: 12000510

Eur J Dermatol. 2002 May-Jun;12(3):272-4.
Tinea barbae due to Trichophyton verrucosum.

Maeda M, Nakashima T, Satho M, Yamada T, Kitajima Y.

Department of Dermatology, Prefectural Gifu Hospital, 4-6-1 Noishiki, Gifu City, 500-8717, Japan.

A 25 year-old male, a dairy farmer, had noticed an annular scaly erythema on the left cheek since 3 weeks, and visited a dermatological clinic for the eruption. Diagnosis of tinea faciei was made and he was treated with oral anti-histamine medicine and by topical application of anti-fungal ointment. However, the eruption worsened and enlarged so that he visited the department of dermatology of Kumiai Hospital on October 19, 1997. He was in good general health. Physical examination disclosed papules and pustules with swelling and erythema on the chin and cheeks. The results of routine laboratory investigations were within normal limits except for white blood cell (9,800/mm(3)) and C reactive protein (2+). A small white-yellowish colony was grown on brain heart infusion agar culture of the biopsied specimen of the lower jaw. Histopathological features showed epidermal hyperplasia with elongation of rate ridges and granulomatous changes around hair follicles in the dermis with many mononuclear cells and giant cells, where many positive spores and fine filamentous structures with PAS and Grocott stains were seen. Based on clinical, histopathological and mycological findings, a diagnosis of Trichophyton verrucosum was made. The patient was treated with oral itraconazole (100 mg/day) for two months. There was a good clinical response and no recurrence during three years and six months.

Publication Types:
Case Reports
PMID: 11978571

Rev Iberoam Micol. 2002 Mar;19(1):36-39.
[Clinical and epidemiological survey of dermatophytoses in Jaen (Spain)]

[Article in Spanish]

Padilla A, Sampedro A, Sampedro P, Delgado V.

Centro de Salud El Valle, Jaen, Espana.

Prevalence of dermatophytosis, with respect to age and sex and dermatophyte species, in Jaen was investigated during a period of three years (1996-1999). The prevalence of dermatophytosis over three years was 4.48 cases / 1000 inhabitants. The isolated species were: Microsporum canis (48.6%), Trichophyton mentagrophytes (27.1%), Epidermophyton floccosum (10%), Trichophyton rubrum (8.6%), Trichophyton violaceum (4.3%), and Microsporum gypseum (1.4%). The most frequently observed dermatophytoses were tinea corporis (62.8%), followed by tinea capitis (12.8%); other clinical forms encountered were, in decreasing order of frequency, tinea cruris, tinea pedis and tinea unguium, tinea faciei and tinea barbae. Men were more affected than women.
PMID: 12716229

Hautarzt. 2003 Mar;54(3):265-7. Epub 2003 Jan 11.
[Herpetic folliculitis barbae. A rare cause of folliculitis]

[Article in German]

Anliker MD, Itin P.

Dermatologische Abteilung, Medizinische Klinik, Kantonsspital Aarau, Switzerland.

Viral folliculitis is a rare disease usually caused by herpes simplex, herpes zoster and molluscum contagiosum in immune-compromised patients. An otherwise healthy 30 year old patient without history of herpes simplex contracted a folliculitis in the beard region after a flu-like illness. He had no oral or labial lesions but instead showed a crusty erythematous folliculitis confined to the beard region with small grouped vesicles on the neck and reactive cervical lymph nodes. Bacterial and mycological analysis from swabs were negative. The culture was positive for herpes simplex virus and the immune fluorescence showed HSV type 1. Systemic therapy with valaciclovir 2x 500 mg/d and lotio alba locally led to rapid improvement. When confronted with folliculitis, non-bacterial causes such as viral (herpes simplex, herpes zoster, molluscum contagiosum), mycological (pityrosporon, candida), demodex and eosinophilic follicultitis should be taken under consideration.

Publication Types:
Case Reports

PMID: 12634996

Mycoses. 2003 Feb;46(1-2):60-3.
Tinea barbae caused by a zoophilic strain of Trichophyton interdigitale.

Trotha R, Graser Y, Platt J, Koster A, Konig B, Konig W, Freytag C.

Institut fur Medizinische Mikrobiologie, Otto-von-Guericke-Universitat, Magdeburg, Germany.

A deep absceding infection is reported of the inframandibular part of the face of a 22-year-old male student due to a zoophilic strain of Trichophyton interdigitale. The fungus was probably acquired from the cat of the patient. Initial therapy by a general practitioner was with topical glucocorticoids and oral antihistaminica. The patient developed a severe phlegmoneous inflammation of the bearded part of the face. Later, the patient was successfully treated by a combination of itraconazole and fluconazole. Identification of the species was confirmed by light and scanning microscopy as well as sequence analysis of the internal transcribed spacer region of the ribosomal DNA.

Publication Types:
Case Reports

PMID: 12588486

Am Fam Physician. 2003 Jan 1;67(1):101-8.
Dermatophyte infections.

Hainer BL.

Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.

Dermatophytes are fungi that require keratin for growth. These fungi can cause superficial infections of the skin, hair, and nails. Dermatophytes are spread by direct contact from other people (anthropophilic organisms), animals (zoophilic organisms), and soil (geophilic organisms), as well as indirectly from fomites. Dermatophyte infections can be readily diagnosed based on the history, physical examination, and potassium hydroxide (KOH) microscopy. Diagnosis occasionally requires Wood’s lamp examination and fungal culture or histologic examination. Topical therapy is used for most dermatophyte infections. Cure rates are higher and treatment courses are shorter with topical fungicidal allylamines than with fungistatic azoles. Oral therapy is preferred for tinea capitis, tinea barbae, and onychomycosis. Orally administered griseofulvin remains the standard treatment for tinea capitis. Topical treatment of onychomycosis with ciclopirox nail lacquer has a low cure rate. For onychomycosis, “pulse” oral therapy with the newer imidazoles (itraconazole or fluconazole) or allylamines (terbinafine) is considerably less expensive than continuous treatment but has a somewhat lower mycologic cure rate. The diagnosis of onychomycosis should be confirmed by KOH microscopy, culture, or histologic examination before therapy is initiated, because of the expense, duration, and potential adverse effects of treatment.

Publication Types:

Review, Tutorial
PMID: 12537173

Nippon Ishinkin Gakkai Zasshi. 2003;44(3):209-16.
[Analysis of dermatophyte flora at a private clinic in Sapporo during the period 1992 to 2001]

[Article in Japanese]

Shibaki H, Shibaki A.

Shibaki Dermatology Clinic, Teine honcho 2-4, Teine-ku, Sapporo 006-0022.

Statistical analysis was made of a total of 5530 patients (6798 cases) of dermatophytoses presenting at our private clinic during the period 1992 to 2001. The number of patients and cases represents 8.0% and 9.8% of the entire outpatient population during that time, respectively. Sex ratio (male/female) was 1.5. Among the 6798 dermatophytoses cases, tinea pedis was most frequent (65.8%), followed by tinea unguium (20.7%), tinea cruris (7.2%), tinea corporis (3.9%), tinea manuum (2.4%) and tinea barbae (0.04%). The incidence of tinea unguium increased, whereas that of tinea pedis, tinea cruris, and tinea corporis decreased during this ten year period, and 35.8% of dermatophytoses patients had more than two clinical subtypes simultaneously. Three thousand seven hundred ninety-five dermatophytes were isolated during the survey. : Trichophyton rubrum (TR)(79.4%), Trichophyton mentagrophytes ™(19.5%), Microsporum canis (MC)(0.7%), Epidermophyton floccosum (EF) (0.3%), and Microsporum gypseum (MG) (0.1%). Compared with our previous analysis reported for the period 1982 to 1991, the frequency of dermatophytoses increased, especially among aged individuals. Of the clinical subtypes, tinea pedis and tinea unguium were higher, but tinea cruris and tinea corporis were lower, and tinea capitis was not seen in the current survey. Among dermatophytes, TR was increased and other types of fungi were decreased. TR was 4.08 times more common than TM; this ratio is higher than our previous report.
PMID: 12913811

For pseudofolliculitis information:

Those looking to clear up razor bumps or PFB should read the article below:

HairTell Premium article on pseudofolliculitis barbae (PFB)