Feisty Follicle

When a hair follicle becomes inflamed, it may become a papule or a pustule and look just like acne! Yes, there are more “acne pretenders” besides the ones I talk about in earlier article. I further explore your hair follicle, a place that can also serve as a location for other pretenders — razor bumps and keratosis pilaris.

Razor Bumps

If you’re a guy with curly hair (and much less often a woman), the area under your chin, upper neck, or cheeks can be subject to an uncomfortable cluster of papules and sometimes pustules, which can make shaving very difficult. This condition is known as pseudofolliculitis barbae (PFB); more commonly called razor bumps.

That’s right, “pseudo” as in phony. Although no one would argue that your inflamed follicles are fake, your condition isn’t actually folliculitis. The term folliculitis simply refers to any inflammation or infection of hair follicles. Besides being a cosmetic liability, these bumps can really become itchy, painful, and tender.

In addition to the papules and pustules, if the condition goes unchecked, the following lesions may ultimately result:

  • Persistent flesh-colored bumps: These lesions are actually hypertrophic scars that sometimes go on and result in keloids.
  • PIP: Postinflammatory pigmentation, or dark spots, may also become a prominent feature on people with PFB.

PFB is a condition that can appear in folks from all ethnic backgrounds. It’s extremely common in men of African descent as well as some men of Hispanic origin and non-Hispanic Caucasians with curly hair. And yes, it can also be a plague to some women in these groups.

Examining follicle causes

People with curly hair have curved hair follicles. Most African- American people have curved hair follicles. The majority of Caucasians and virtually all Asians have straight hair follicles that produce straight hairs, which explains why we see more African- American men with PFB. PFB lesions are seen on the beard area — particularly on the neck and below the jawbone.

Ingrown hairs

Because the hair shafts of people with curly hair are curved, the hairs that emerge from their follicles tend to be tightly coiled. It’s true of beard hair as well as other body hair. After shaving, a single curly hair becomes a sharply pointed tip that if aimed toward the body, can grow right back into the skin. Figures A and B illustrate the process.

When shaved, the curly hair emerging from a curved follicle becomes a sharp tip that curves downward as it grows (A), and reenters the skin (B). When hair is cut too closely (C), it may grow parallel to the skin and penetrate the side of the follicle (D).

The penetration of sharp hairs causes a misguided reaction by your body’s immune system that sees your penetrating hairs as “foreign invaders.” Your immune system overreacts by attacking the hair with white blood cells and thus produces inflammatory papules and pustules that resemble acne.

Shaving below the surface

When they’re shaved too closely, hairs can also grow parallel to the skin and penetrate the side of the follicle. Check out Figures C and D. This penetration also causes a reaction of your immune system, producing papules and pustules.

Adding insult to injury

Furthermore, newly erupting hairs from below may pierce and aggravate areas that are already inflamed. Thus, growing hair or hairs that have been plucked may traumatize an existing papule or pustule. Try your best not to pluck hairs growing in areas in which you have PFB, because new hairs will again grow from below and penetrate a site that is already inflamed.

Shaving correctly with PFB

If you have PFB, you need to establish proper shaving techniques. Allowing you hairs to grow long enough so they won’t grow back into the skin can be helpful, or you might decide to stop shaving permanently! Growing a beard is probably the best way to prevent PFB, though most people don’t choose this option.

If you want to try the stop-shaving approach but you’re in the military, law enforcement, or work in a company that requires you to be clean-shaven, ask your healthcare provider to give you a letter that explains your PFB condition and why you should be excused from shaving. If you intend to keep on shaving, the following sections give you some tips on preventing PFB.

The key with all of these techniques is to reduce how close the shave is so that you reduce the chance of ingrown hairs. Hairs cut too short are at risk of curling into the skin while growing and causing more razor bumps. Whatever method you choose when shaving, be sure to use the sharpest implement.

Razor shaving

Just like washing your face, shaving is a little more complicated than some people think, especially if you’re prone to skin problems such as PFB. You can avoid a close shave by using a guarded razor. Two that I recommend are the PFB Bump Fighter or an Aveeno PFB Bump Fighter Razor.

Both of these products should be available at your local drugstore. These razors are covered with a plastic coating that prevents the razor from contacting the skin directly and produces less trauma to the skin. Here are my tips for shaving in the most pain-free and healthy way:

  • Soften your hairs before shaving. Try shaving after you take a warm shower. Steaming helps to soften your beard. Washing your face before shaving removes oil and causes hairs to become more erect, making them easier to cut. Lather the beard area with a non-irritating, lubricating shaving gel such as Aveeno Therapeutic Shave Gel, Edge, or a benzoyl peroxide- containing prescription shaving foam such as BenzaShave.
  • Use shaving gels to hydrate your hairs and to provide lubrication between the razor blades and your skin.
  • Shave with downward strokes. Go with the grain. Shaving in the same direction that the hair lies (typically down) will result in less pull on the hairs and less tendency to cut them too short. Shaving with the grain will also minimize skin irritation.
  • Minimize repeat shaving strokes. Not only is it a waste of time and energy to go over and over the same area, but repeated shaving may result in hairs being cut too short.
  • Don’t stretch the skin during shaving because this leads to a closer shave and increases the chances of producing ingrown hairs. Don’t shave on a daily basis if you don’t have to.
  • Don’t use aftershave or cologne on the shaved areas. Instead, after shaving is finished, rinse thoroughly with warm water and apply a mild moisturizing aftershave lotion such as Cetaphil Lotion.
  • Rinse your razor of all cut hairs at regular intervals. It helps to reduce the drag across the skin. Change your blades at least once a week and more often if skin irritation persists.
  • Be sure not to use those double, triple, and quadruple razors, which wind up shaving you two, three, and four times! These modern razors are so good at what they do, they shave below the skin surface and only make things worse.

Electric shaving

Using an electric razor with gentle pressure is another method that reduces the closeness of the shave. Just as with a wet razor, an electric razor should be cleaned regularly so that the mechanism doesn’t become clogged with hairs.

When using an electric shaver, you want the hairs to be dry and stiff before you begin, so they’re easier to cut. So you should not start by washing your face or thoroughly wetting the beard with water as you do with a wet shave with a blade. Instead, you may want to apply a pre-shave lotion designed for electric shavers (such as Lectric Shave).

Such products, often alcoholbased, dry up the oils and moisture on your skin and make the whiskers stand straight up. Try using electric hair clippers that leave the cut hairs long. Aim to have a “five o’clock shadow” immediately after shaving.

Treating razor bumps on your own

The good news about PFB is that it can be treated. You can start by treating it yourself, using the physical method I recommend in the next section. You can also use topical medications that contain benzoyl peroxide. If you don’t get satisfactory results, contact your dermatologist for help. He can evaluate your condition and help you take the next steps.

Physically stopping PFB

A curled hair can be flipped up before it has a chance to plunge into the skin by using a fine needle or toothpick to gently lift it before reentry.

  1. Inspect your beard to look for potential plunging hairs or for hairs that have already taken the plunge. Prime candidates include those that are pointing back toward your skin or those that are lying flat.
  1. Use a fine needle or toothpick to lift the hair between the follicle and the tip.
  1. Gently redirect the sharp pointed end of the hair away from your skin.

Probing too aggressively with a needle or toothpick can lead to further inflammation

Buying benzoyl peroxide

Benzoyl peroxide is the most commonly used over-the-counter acne medication, and is also the most effective medication for treating PFB. It comes in varying strengths ranging from 2.5 to 10 percent.

There’s no proof that anything higher than 2.5 percent works any better than the higher concentration, and the lower concentrations are cheaper and may be less irritating to your skin. Clear By Design, Clearasil, Fostex, Neutrogena, and Noxzema are just a few of the benzoyl peroxide brand names available.

A cream or water-based product may be gentler if your skin is very sensitive; however, alcohol-based products may be more potent if you’re able to tolerate them. Experiment with the different products until you find the right one for you. Here are some application tips:

  • Apply the benzoyl peroxide sparingly in a very thin layer to the entire PFB-prone areas once or twice a day. You may have to continue applying it for as long as you have the problem, or you can try stopping it for periods of time when the PFB comes under control.
  • Avoid abrasive, harsh, or drying soaps and cleansers while using benzoyl peroxide.

Be patient, your PFB often responds very slowly to treatment. It may take six to eight weeks before you notice any improvement. Dryness of the treated area can be expected and is usually mild.

You may experience a mild burning sensation or reddening of the skin when you first start to apply benzoyl peroxide. These symptoms usually disappear in two to three weeks. For more information on using benzoyl peroxide.

Other OTC products

In addition to benzoyl peroxide, topical fruit acids, such as glycolic acid and salicylic acid, products that contain lactic acid, and mixtures of all three are also advertised as PFB treatments. They’re not as effective as benzoyl peroxide, and I only mention glycolic acid here.

  • Glycolic acid: Besides benzoyl peroxide, glycolic acid, which is an alpha hydroxy acid (AHA), is the most common ingredient found in over-the-counter PFB products. It’s found in many cosmetics and moisturizers.

Examples of glycolic acid preparations are Alpha-Hydrox and Neo-Strata. Cleansers containing glycolic acid and other AHAs can be used prior to shaving with a razor and moisturizers that have an AHA in them are recommended after shaving.

  • Hydrocortisone cream: You can purchase over-the-counter 1 percent hydrocortisone cream, which is topical cortisone for itching or irritation. Apply a small amount once or twice a day for itching or stinging, only if necessary.

Getting professional help

If going it alone isn’t working out, you may need to see your dermatologist or healthcare provider about getting a prescription medication for your PFB. (If you don’t already have a doctor you trust to help you with this problem, turn to "Finding Acne Experts" where I tell you how to go about finding the right doctor for you.)

Combining benzoyl peroxide with topical antibiotics

If over-the-counter isn’t working for you, prescription benzoyl peroxide combined with a topical antibiotic such as Benzamycin, Duac, or BenzaClin gel may work very well for you. To save a little money, you could also talk to your doctor about using a prescription for a generic topical antibiotic such as clindamycin or erythromycin lotion along with an over-the-counter benzoyl peroxide.

Use them one on top of the other. As with applying benzoyl peroxide alone, it may take six to eight weeks for the product to work and the same potential side effects of dryness and irritation may also apply. Benzoyl peroxide also is available as prescription shaving foam known as BenzaShave.

If you have supersensitive skin, prescription Akne-Mycin (erythromycin, 2 percent) ointment may be right for you. It also may take six to eight weeks for it to work. It’s less harsh on your skin. Here are some general tips for using these medications for PFB:

  • Apply medication sparingly in a very thin layer to your PFBprone areas once or twice a day.
  • If you must shave, apply the medication after you shave. Wait at least 30 minutes to cause the least irritation.
  • Apply a moisturizer over the medicine to help prevent dry skin and other irritation.

Using topical retinoids

As with the treatment of acne, the topical retinoids appear to help reduce the inflammatory lesions of PFB. Topical retinoids can perform a double duty for you. In addition to the beneficial actions of the retinoids in treating some of the inflammatory lesions of PFB, they also lighten PIP (if you have it) as well.

Adaplene (Differin), tazarotene (Tazorac), Avita, and tretinoin (Retin- A) are all prescription retinoids. Check out "Topical Tools For Acne Treatment" for more information about prescription-strength topical acne medication. Apply topical retinoids in small, thin, pea-sized amounts to the PFB-prone areas.

Creams are the least irritating, so you probably should start out with a cream-based retinoid instead of a gel. All retinoids can cause some skin irritation during the first few weeks. You may have some discomfort, such as stinging or burning and, sometimes, mild scaling of your skin.

If you have a sensitivity to the retinoid you were prescribed, then use it every other day, or even less frequently, until you get used to it. Maximal improvement most often occurs within three to four months.

Trying other topical measures

Your dermatologist has a few other topical tools at his disposal. Consider these additions to your topical therapy if you’re itching or have dark spots and your doctor feels you need them:

  • A prescription-strength topical cortisone cream may be helpful if you have a great deal of itching or irritation.
  • Glyquin, a combination of glycolic acid and hydroquinone (a bleaching chemical) is a moisturizing cream especially helpful for those with PFB and PIP. Apply it once or twice a day.

Opting for oral antibiotics

When your beard becomes populated with papules and pustules, gets to be super itchy, or your scars seem to be growing, it’s time for more aggressive therapy. At times like this, your dermatologist may elect to treat your PFB with oral as well as topical preparations. Oral antibiotic drugs have an anti-inflammatory action that helps to clear inflammatory lesions (papules and pustules).

Injecting the bumps with cortisone

When scars become unsightly or the papules become itchy or painful, a very common method to deal with them is by injecting the lesions with cortisone. The shots are given in addition to oral and topical antibiotics.

Intralesional cortisone injections (a relatively painless procedure) can be extremely effective in reducing the inflammation and sometimes the size of inflammatory papules and hypertrophic scars. They also help decrease itching. This usually requires repeated treatments because PFB is a chronic problem.

Dealing with Those Hairs

Whether you’re a man or a woman, if you discover some dark hairs on your chin, cheeks, or neck, you may find them to be annoying or cosmetically objectionable. If you have PFB, this section offers some ideas to lessen your follicular problems. Your excess hairs may be due to hirsutism, an excess of hair in a masculine pattern seen in women. Hirsutism can be seen in certain cases of hard-to-treat acne.

You may also have excessive hair growth on other areas besides your face such as on your chest, nipples, and pubic area. This section provides lots of solutions for this condition as well. Many methods are available for temporary or permanent hair removal. The following sections go over some different methods.

Removing hairs temporarily

Technically referred to as epilation, plucking, tweezing, and waxing are common choices for temporary hair removal. These methods remove the intact hair with its root. Performed by aestheticians or by yourself, these procedures are commonly used and are safe; however, they can sometimes result in irritation and folliculitis.

As you may know, your hair will still grow back with these approaches. But contrary to myth, shaving, plucking, and tweezing don’t promote heavier hair growth. Chemical depilatories are another option. Depilatories remove hair from the surface of the skin.

They separate the hair from its follicle by destroying the bonds that hold the hairs together. Nair and Neet are commercially available products. For PFB, chemical depilatories such as Magic Shave and Royal Crown Powders are effective in removing and softening hairs.

Chemical depilation may be best suited for treatment of large hairy areas in people who are unable to afford more expensive treatments such as electrolysis and laser epilation. The main disadvantages of chemical depilatories are irritation of the skin and the unpleasant odor of the products.

These products dissolve the hairs but can be too strong and cause chemical burns on facial skin. Until you see how your skin reacts to a chemical depilatory, leave these products on your skin for less time than is recommended on the package instructions.

Removing hairs permanently

Techniques of permanent epilation include electrolysis, thermolysis, and laser epilation.

Electrolysis and thermolysis

Hair destruction by electrolysis or thermolysis is performed with a fine, flexible electrical wire (probe) that produces an electrical current after being introduced down the hair shaft. The electricity is delivered to the follicle through the wire, which causes localized damage to the areas that generate hairs.

Thermolysis (diathermy) employs a high-frequency alternating current and is much faster than the traditional electrolysis method, which uses a direct galvanic current. Thermolysis works by causing water molecules in the skin around the probe to vibrate, which creates heat. If enough heat is produced, it can damage the cells that cause hair growth.

Electrolysis and thermolysis are slow processes and require multiple treatments for permanent results. Both electrolysis and thermolysis are excellent procedures to accomplish permanent hair removal, however, treatments can be rather uncomfortable and can worsen PFB, create folliculitis, and result in postinflammatory pigmentary (PIP) changes in the skin.

These methods are difficult to use on inflammatory lesions. Make sure to find a competent electrologist. Ask around. One of the best ways to find a good one is to ask friends and family for recommendations. These practitioners can be found in beauty salons, doctor’s offices, personal offices, or they may work out of their own homes.

Many states require that electrologists be licensed or certified within the state in order to practice electrolysis. For states that do not regulate electrolysis, look for electrologists who have a certification from an accredited electrology school.

Laser epilation

Lasers can treat larger areas and do it faster than electrolysis and thermolysis. They have skin-cooling mechanisms that minimize skin damage during the procedure. Skin and hair color often determine if a laser should be used. Lasers are most effective on dark hairs on fair-skinned people. As with electrolysis and thermolysis, multiple treatments are often necessary for long-term hair destruction.

Results are inconclusive regarding whether lasers are more effective in permanent hair removal than the more traditional methods such as electrolysis. They’re certainly more costly. In dark-skinned people, the Nd:YAG laser seems to be safe and effective. This laser is currently the most effective laser for hair removal in dark-skinned individuals who have PFB.

Slowing down the hairs

Vaniqa (eflornithine hydrochloride cream) is a prescription topical cream that works by inhibiting an enzyme required for hair growth. It is indicated for the reduction of unwanted facial hair in women and must be used continuously to be effective. You may notice results after four to eight weeks, but your hair growth will return if you stop using the cream.

Oral treatment with anti-androgens should be considered when hirsutism is associated with an underlying disorder. Androgen inhibition with spironolactone or flutamide is sometimes used when medical reasons are identified as the cause of the hirsutism. All of these drugs must be given continuously because when they’re stopped, androgens revert to their former level.

Keratosis Pilaris

Keratosis pilaris (KP) is a very common skin disorder that tends to run in families. Although the condition isn’t serious, it can be frustrating because it’s difficult to treat. It begins most often in childhood and often continues into adulthood. KP results from the buildup of keratin (coarse proteins in your skin that form your hair and nails) that plugs the openings of hair follicles in the skin.

KP is particularly common in teenagers on the upper arms and it tends to be most obvious when it occurs on the cheeks. Lesions may remain for years but they may gradually diminish or even disappear before age 30. KP can be unsightly, but it is completely harmless.

Distinguishing KP from acne

KP occurs as small, rough patches — usually on the arms and sometimes on the cheeks. It can also appear on the thighs and buttocks. It causes no pain or itching. It has a sandpaper-like feel to it and looks like gooseflesh. The diagnosis of KP can often be made by simply rubbing the area with your hands.

Often, there may be some red papules mixed in with the rough bumps. I bring the subject of KP up because healthcare providers so often mistake it for acne. The whitish papules tend to look like closed comedones (whiteheads) and the red papules tend to resemble the inflammatory lesions of acne, whereas in reality KP is a disorder of hyperkeratosis (too much keratin).

Treating the hair bumps

No cure or very effective treatment is available for KP. However, the good news is that in most people the bumps usually diminish in number with increasing age. Treatment is directed at softening the keratin deposits in the skin and may include medicated creams and lotions that contain either urea, such as Carmol 20, or lactic acid, such as AmLactin Moisturizing Lotion.

You can also use petroleum jelly, cold cream, or 2 percent salicylic acid (which removes the top layer of skin) to flatten the pimples. Topical retinoids such as tretinoin, Retin-A Micro, and Differin cream have all been used to treat KP. The results have not been impressive, however.