Folliculitis Keloidalis Nuchae and Pseudofolliculitis Barbae

Are Prevention and Effective Treatment Within Reach?

      Keywords

      Key points

      • Pseudofolliculitis barbae (PFB) is an inflammatory follicular disorder associated with shaving, most commonly seen in men of African ancestry.
      • Follicular penetration from ingrown hairs is the primary inciting factor in PFB.
      • In the appropriate patient, an effective prevention strategy for PFB is to grow a beard, but optimization of shaving practices (including pre- and postcare) is a useful approach for men who wish to continue shaving.
      • Folliculitis keloidalis nuchae (FKN) is a follicular-based disorder mainly affecting the nape of the neck; histopathologically, FKN has characteristics of a primary cicatricial alopecia.
      • PFB and FKN are chronic conditions requiring continual maintenance strategies.

      Introduction

      Pseudofolliculitis barbae (PFB) and folliculitis keloidalis nuchae (FKN) are chronic follicular disorders that disproportionally affect men of African ancestry. Though common, these conditions are often therapeutically challenging, requiring pharmacologic, procedural, and behavioral approaches to treatment. In this article the epidemiology, pathogenesis, clinical findings, treatment options, prevention, and new advances with regard to PFB and FKN are discussed. The possibility of achieving effective preventive measures and treatments is also explored.

      Pseudofolliculitis barbae

       Epidemiology

      PFB is a common follicular disorder most prevalent in men of African ancestry.
      • Coley M.K.
      • Kelly A.P.
      • Alexis A.F.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      • Quarles F.N.
      • Coley M.K.
      • Alexis A.F.
      Dermatological disorders in men of African descent.
      • Coley M.K.
      • Alexis A.F.
      Dermatologic conditions in men of African ancestry.
      It is also frequently observed among Hispanic, Middle Eastern, and other populations in whom tightly curled hair is common. Among African American men, the incidence of PFB is 45% to 83%.
      • Perry P.K.
      • Cook-Bolden F.E.
      • Rahman Z.
      • et al.
      Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
      • Alexander A.M.
      • Delph W.I.
      Pseudofolliculitis barbae in the military. A medical, administrative and social problem.
      • Edlich R.F.
      • Haines P.C.
      • Nichter L.S.
      • et al.
      Pseudofolliculitis barbae with keloids.
      PFB may also occur in any race and may also affect women.
      • Coley M.K.
      • Kelly A.P.
      • Alexis A.F.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      • Bridgeman-Shah S.
      The medical and surgical therapy of pseudofolliculitis barbae.
      • Kelly A.P.
      Pseudofolliculitis barbae.

       Pathogenesis

      PFB is a chronic, noninfectious inflammatory disorder resulting from a foreign-body reaction to the hair shaft. Individuals who have coarse, tightly curled hair and who shave are predisposed to this condition, owing to the tendency for the distal portion of tightly curled hair shafts to reenter the skin after shaving. Reentry of shaved hair shafts can occur through 1 of 2 mechanisms: (1) extrafollicular penetration, whereby the shaved hair shaft grows along its natural curvature and penetrates the epidermis 1 to 2 mm distal to the follicular opening; or (2) transfollicular penetration, whereby the sharp distal tip of a shaved hair shaft retracts beneath the skin surface, pierces the follicular wall, and enters the dermis. Stretching the skin during shaving or close shaving techniques can contribute to transfollicular penetration.
      • Perry P.K.
      • Cook-Bolden F.E.
      • Rahman Z.
      • et al.
      Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
      • Brown Jr., L.A.
      Pathogenesis and treatment of pseudofolliculitis barbae.
      • Halder R.M.
      Pseudofolliculitis barbae and related disorders.
      Hair reentry (via either extrafollicular or transfollicular penetration) results in a chronic, foreign-body inflammatory response.
      • Coley M.K.
      • Kelly A.P.
      • Alexis A.F.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      In addition to this mechanical etiology, a genetic risk factor has been identified that can affect a subset of men with PFB. A substitution mutation in the 1A α-helical segment of the hair-follicle–specific keratin 75 (formerly K6hf) was found in 36% of PFB cases compared with 9% in controls (P<.000006). This single nucleotide polymorphism may be associated with a structurally weakened companion layer of the hair follicle which, along with curly hair shafts and close shaving, contributes to an increased risk for PFB.
      • Winter H.
      • Schissel D.
      • Parry D.A.
      • et al.
      An unusual Ala12Thr polymorphism in the 1A alpha-helical segment of the companion layer-specific keratin K6hf: evidence for a risk factor in the etiology of the common hair disorder pseudofolliculitis barbae.

       Clinical Features

      The clinical hallmarks of PFB are follicular and/or perifollicular papules in an area where repetitive shaving has occurred (Fig. 1). In men, the most commonly affected area is the neck (Fig. 2) followed by the cheeks, whereas in women the chin (especially the submental region) is the most commonly affected area.
      • Perry P.K.
      • Cook-Bolden F.E.
      • Rahman Z.
      • et al.
      Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
      Of note, the moustache and nuchal areas are rarely affected. Hirsute women who shave or pluck unwanted hairs frequently develop PFB on the chin and neck area (Fig. 3). Shaving the axillae and bikini region of the groin, a common practice among women of all races, can lead to pseudofolliculitis in these areas.
      • Bridgeman-Shah S.
      The medical and surgical therapy of pseudofolliculitis barbae.
      Figure thumbnail gr1
      Fig. 1Pseudofolliculitis barbae with characteristic perifollicular papules and pustules on the beard area. Note the associated postinflammatory hyperpigmentation.
      Figure thumbnail gr2
      Fig. 2Pseudofolliculitis barbae involving the neck (the most common region affected in men with this disorder).
      Figure thumbnail gr3
      Fig. 3Pseudofolliculitis barbae involving the chin and submental region in a woman with hirsutism who tweezed and shaved unwanted hairs.
      The papules of PFB may be firm, skin colored, erythematous, or hyperpigmented. If secondary infection arises, pustules and papulopustules may be present.
      • Kelly A.P.
      Pseudofolliculitis barbae.
      Some papules may contain visible hairs.
      • Coley M.K.
      • Alexis A.F.
      Dermatologic conditions in men of African ancestry.
      Linear depressions in the affected skin areas likely represent hairs that are growing parallel to the surface of the skin (Fig. 4).
      • Perry P.K.
      • Cook-Bolden F.E.
      • Rahman Z.
      • et al.
      Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
      Potential sequelae include postinflammatory hyperpigmentation (PIH) and keloids.
      • Coley M.K.
      • Kelly A.P.
      • Alexis A.F.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      Pruritus and pain are also potential associated clinical features.
      • Coley M.K.
      • Alexis A.F.
      Dermatologic conditions in men of African ancestry.
      • Kelly A.P.
      Pseudofolliculitis barbae.
      Figure thumbnail gr4
      Fig. 4Severe pseudofolliculitis barbae involving the neck. Note coarse hair shafts growing tangentially on the upper third of the neck.
      The differential diagnosis of PFB includes acne vulgaris, sycosis barbae, and traumatic folliculitis. No comedonal lesions are found in PFB, and acne vulgaris affects other areas of the face in addition to the beard area. Pustules are common in acne vulgaris, whereas they are rare in PFB. In sycosis barbae, perifollicular pustules are the primary and predominant lesions. Lesions in PFB are isolated, whereas in sycosis barbae they are confluent. Shaving improves sycosis barbae, whereas it makes PFB worse. Traumatic folliculitis, commonly known as razor burn, occurs when shaving is done too closely. Lesions are erythematous, painful, small follicular papules, which disappear within 24 to 48 hours after shaving. Pseudofolliculitis barbae persists for several weeks after cessation of shaving.

       Management

      The goal of PFB management is to improve the cosmetic appearance of the affected area, enhance one’s self-esteem, appropriately address impacts of PFB on occupational requirements, and prevent further complications such as hypertrophic scarring, keloidal scarring, or infection.
      Setting reasonable expectations regarding potential treatment outcomes is a priority. PFB is a chronic problem for which the only true cure is growing a beard or having the hairs permanently removed.

      Kelly AP. Pseudofolliculitis barbae. In: Arndt K, LeBoit P, Robinson J, et al, editors. Cutaneous medicine and surgery. vol. 1. 1996. Philadelphia: W.B. Saunders p. 499–503.

      Many patients are disturbed by the appearance of PFB lesions. Not only do these lesions potentially impact self-esteem, they may also lead to an inability to comply with workplace grooming policies. Men working in jobs requiring a close-shaven appearance may experience personal distress, along with repercussions from employers. Occupations such as flight attendant, police officer, and food service worker often require a close shave. African Americans in the military are often forced to choose between worsening their PFB with close shaves or be at risk for discharge from the armed forces.
      • Perry P.K.
      • Cook-Bolden F.E.
      • Rahman Z.
      • et al.
      Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
      • Alexander A.M.
      • Delph W.I.
      Pseudofolliculitis barbae in the military. A medical, administrative and social problem.
      • Brauner G.J.
      • Flandermeyer K.L.
      Pseudofolliculitis barbae. Medical consequences of interracial friction in the US Army.
      • McMichael A.J.
      Hair and scalp disorders in ethnic populations.
      Treatment options for PFB are summarized in Table 1. The initial consultation for a patient with PFB should begin with a detailed discussion of therapeutic options and can involve a stepwise approach (Fig. 5). The first step is offering the patient the option of growing a beard, as discontinuation of shaving for at least 1 month has been shown to be curative in most cases. Patients who choose this option may require a physician letter for their employer to permit them to maintain a well-groomed beard in their professional setting. For patients who prefer not to have a beard, recommendations are directed toward minimization of hair shaft reentry and reduction of inflammation. Modification of shaving practices, including the addition of preshave and postshave regimens, is helpful in achieving these goals. Before shaving, the beard area should be prepped by washing with warm water and a mild soap-free cleanser. Using a wash cloth or polyester cleansing pad in a circular motion is a helpful technique aimed at gently releasing embedded hair shafts before shaving. Preshave washing regimens (using a scrub or brush) have been shown to reduce the percentage of trapped beard hairs.
      • Cowley K.
      • Vanoosthuyze K.
      Insights into shaving and its impact on skin.
      Shaving should be performed with a clean, sharp razor with the skin in its relaxed state (stretching of the skin should be avoided, as this may facilitate transfollicular penetration of hairs shaved slightly below the skin surface). Shaving in the direction of hair growth (ie, with the grain) has been generally recommended
      • Perry P.K.
      • Cook-Bolden F.E.
      • Rahman Z.
      • et al.
      Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
      ; however, a recently published study found that men who reported shaving against the grain had lower papule counts.
      • Daniel A.
      • Gustafson C.J.
      • Zupkosky P.J.
      • et al.
      Shave frequency and regimen variation effects on the management of pseudofolliculitis barbae.
      Traditionally, single-blade razors have been favored over multiple-blade razors because of concerns about transfollicular penetration associated with the closer shave achieved with multiple-blade razors. However, in a recent study, PFB was not exacerbated by the use of multiple-blade razors (in conjunction with a preshave cleanser and postshave lotion).
      • Daniel A.
      • Gustafson C.J.
      • Zupkosky P.J.
      • et al.
      Shave frequency and regimen variation effects on the management of pseudofolliculitis barbae.
      Regardless of choice of a single-blade or multiple-blade razor, a clean, sharp razor blade should be used for each and every shave. Published comparative studies of single-blade versus multiple-blade razors or electric versus manual razors in patients with PFB are currently lacking, as are studies that prospectively investigate the effects of shaving direction on PFB severity.
      Table 1Treatment options for pseudofolliculitis barbae (PFB) and folliculitis keloidalis nuchae (FKN)
      PharmacologicProcedural
      PFB Treatment Options
      • Topical retinoids
        • Keratolytic
          • Kligman A.M.
          • Mills Jr., O.H.
          Pseudofolliculitis of the beard and topically applied tretinoin.
        • Treats concomitant PIH
          • Coley M.K.
          • Kelly A.P.
          • Alexis A.F.
          Pseudofolliculitis barbae and acne keloidalis nuchae.
          • Quarles F.N.
          • Coley M.K.
          • Alexis A.F.
          Dermatological disorders in men of African descent.
          • Bulengo-Ransby S.M.
          • Griffiths C.E.
          • Kimbrough-Green C.K.
          • et al.
          Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients.
      • Low- to mid-potency topical corticosteroids
        • Anti-inflammatory
          • Coley M.K.
          • Kelly A.P.
          • Alexis A.F.
          Pseudofolliculitis barbae and acne keloidalis nuchae.
          • Quarles F.N.
          • Coley M.K.
          • Alexis A.F.
          Dermatological disorders in men of African descent.
          • Kelly A.P.
          Pseudofolliculitis barbae.
      • Intralesional corticosteroids
        • Coley M.K.
        • Kelly A.P.
        • Alexis A.F.
        Pseudofolliculitis barbae and acne keloidalis nuchae.
        • Quarles F.N.
        • Coley M.K.
        • Alexis A.F.
        Dermatological disorders in men of African descent.
        • Kelly A.P.
        Pseudofolliculitis barbae.
      • Topical antibiotics
        • Cook-Bolden F.E.
        • Barba A.
        • Halder R.
        • et al.
        Twice-daily applications of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae.
        • Antimicrobial
          • Perry P.K.
          • Cook-Bolden F.E.
          • Rahman Z.
          • et al.
          Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
        • Anti-inflammatory
          • Cook-Bolden F.E.
          • Barba A.
          • Halder R.
          • et al.
          Twice-daily applications of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae.
      • Bleaching creams for concomitant PIH
        • Hydroquinone, kojic acid, azelaic acid
          • Coley M.K.
          • Kelly A.P.
          • Alexis A.F.
          Pseudofolliculitis barbae and acne keloidalis nuchae.
          • Quarles F.N.
          • Coley M.K.
          • Alexis A.F.
          Dermatological disorders in men of African descent.
          • Coley M.K.
          • Alexis A.F.
          Dermatologic conditions in men of African ancestry.
          • Perry P.K.
          • Cook-Bolden F.E.
          • Rahman Z.
          • et al.
          Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
          • Kelly A.P.
          Pseudofolliculitis barbae.
      • Chemical depilatories
      • Hair growth reduction
        • Eflornithine hydrochloride cream 13.8%
          • Xia Y.
          • Cho S.
          • Howard R.S.
          • et al.
          Topical eflornithine hydrochloride improves the effectiveness of standard laser hair removal for treating pseudofolliculitis barbae: a randomized, double-blinded, placebo-controlled trial.
      • Electrolysis/epilation
        • Potential complications: tedious; needle may not go deep enough to destroy hair bulb
          • Kelly A.P.
          Pseudofolliculitis barbae.
      • Surgical depilation
        • Permanent hair removal, via submandibular excision, hair bulbs electrodesiccated, extracted, or clipped
          • Coley M.K.
          • Alexis A.F.
          Managing common dermatoses in skin of color.
        • Potential complications: expensive; keloid scarring in those prone to keloids in
          • Kelly A.P.
          Pseudofolliculitis barbae.
          • Coley M.K.
          • Alexis A.F.
          Managing common dermatoses in skin of color.
      • Punch excision
        • Kelly A.P.
        Pseudofolliculitis barbae.
        • Kindred C.
        • Oresajo C.O.
        • Yatskayer M.
        • et al.
        Comparative evaluation of men's depilatory composition versus razor in black men.
      • Chemical peels
        • Coley M.K.
        • Kelly A.P.
        • Alexis A.F.
        Pseudofolliculitis barbae and acne keloidalis nuchae.
        • Quarles F.N.
        • Coley M.K.
        • Alexis A.F.
        Dermatological disorders in men of African descent.
        • Coley M.K.
        • Alexis A.F.
        Dermatologic conditions in men of African ancestry.
        • Perry P.K.
        • Cook-Bolden F.E.
        • Rahman Z.
        • et al.
        Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
        • Kelly A.P.
        Pseudofolliculitis barbae.
        • Bulengo-Ransby S.M.
        • Griffiths C.E.
        • Kimbrough-Green C.K.
        • et al.
        Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients.
      • Lasers
        • Diode
          • Smith E.P.
          • Winstanley D.
          • Ross E.V.
          Modified superlong pulse 810 nm diode laser in the treatment of pseudofolliculitis barbae in skin types V and VI.
        • Long-pulse Nd:YAG
          • Daniel A.
          • Gustafson C.J.
          • Zupkosky P.J.
          • et al.
          Shave frequency and regimen variation effects on the management of pseudofolliculitis barbae.
          • Ross E.V.
          • Cooke L.M.
          • Timko A.L.
          • et al.
          Treatment of pseudofolliculitis barbae in skin types IV, V, and VI with a long-pulsed neodymium:yttrium aluminum garnet laser.
        • Potential complications: dyspigmentation, scarring, blistering
      FKN Treatment Options
      Corticosteroids (topical, intralesional), Class I or II corticosteroid gel or foam BID
      • Callender V.D.
      • Young C.M.
      • Haverstock C.L.
      • et al.
      An open label study of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of mild to moderate acne keloidalis.
      Removal with trephine device and secondary-intention healing/primary closure
      • Kelly A.P.
      Pseudofolliculitis barbae and acne keloidalis nuchae.


      Excision of nodules with tissue-expansion mechanisms
      • Kelly A.P.
      Pseudofolliculitis barbae.
      • Kindred C.
      • Oresajo C.O.
      • Yatskayer M.
      • et al.
      Comparative evaluation of men's depilatory composition versus razor in black men.


      Laser
      • Shah G.K.
      Efficacy of diode laser for treating acne keloidalis nuchae.
      • Esmat S.M.
      • Abdel Hay R.M.
      • Abu Zeid O.M.
      • et al.
      The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study.
      Antibiotics (oral) tetracycline derivatives or topical clindamycin for secondary infection
      • Coley M.K.
      • Kelly A.P.
      • Alexis A.F.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      • Quarles F.N.
      • Coley M.K.
      • Alexis A.F.
      Dermatological disorders in men of African descent.
      • Coley M.K.
      • Alexis A.F.
      Dermatologic conditions in men of African ancestry.
      Excision with primary closure
      • Gloster Jr., H.M.
      The surgical management of extensive cases of acne keloidalis nuchae.


      Excision with healing by secondary intention
      • Glenn M.J.
      • Bennett R.G.
      • Kelly A.P.
      Acne keloidalis nuchae: treatment with excision and second-intention healing.
      Corticosteroid gel combined with retinoic acid gel
      • Kelly A.P.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      Electrosurgical excision and secondary-intention healing
      • Beckett N.
      • Lawson C.
      • Cohen G.
      Electrosurgical excision of acne keloidalis nuchae with secondary intention healing.


      Cryotherapy
      • Kelly A.P.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      Abbreviations: BID, twice daily; Nd:YAG, neodymium:yttrium aluminum garnet; PIH, postinflammatory hyperpigmentation.
      Figure thumbnail gr5
      Fig. 5Treatment algorithm for pseudofolliculitis barbae.
      (From Coley MK, Kelly AP, Alexis AF. Pseudofolliculitis barbae and acne keloidalis nuchae. In: Alexis AF, Barbosa VH, editors. Skin of color: a practical guide to dermatologic diagnosis and treatment, 1st edition. New York: Springer; 2013. p. 127; with permission.)
      Electrical razors are useful in controlling PFB, maintaining beard hair at an optimum length of 0.5 to 1 mm to prevent both transfollicular and extrafollicular penetration. Triple-O electric clippers can be used in this regard. These clippers have a protective gap between the comb-like projection that touches the skin and actual razor that cuts the hair. The success of electric clippers in controlling PFB has been impressive. However, clippers leave hair that is approximately 1 mm in length, and the appearance of the remaining stubble may not be acceptable to some patients.
      A foil-guarded manual razor was developed for the treatment of PFB.
      • Alexander A.M.
      Evaluation of a foil-guarded shaver in the management of pseudofolliculitis barbae.
      This razor has a single-edged, polymer-coated, stainless-steel blade with a serrated foil guard covering about 30% of its cutting edge. This guard acts as a partial buffer between the sharp blade and the skin, thus preventing hairs from being cut too close and causing transfollicular penetration. Reported results of shaving with this razor indicate improvement in most patients.
      The judicious use of chemical depilatories (eg, barium sulfide powder or calcium thioglycolate cream formulations) can be a viable alternative to shaving. Barium sulfide depilatories give a smoother shave than calcium thioglycolate depilatories, but are less preferred because of malodor. However, irritant contact dermatitis and erosions are potential limitations. Prolonged contact time should be avoided to reduce the risk of irritation. A recent 1-week, split-faced, randomized trial comparing 3 depilatory formulations with shaving with a manual razor found that the depilatory compositions produced fewer papules than the manual razor, but postshaving irritation was more common with the depilatories.
      • Kindred C.
      • Oresajo C.O.
      • Yatskayer M.
      • et al.
      Comparative evaluation of men's depilatory composition versus razor in black men.
      Pharmacologic treatments for PFB include low-potency topical corticosteroids (eg, desonide lotion), benzoyl peroxide formulations, topical antibiotics, and topical retinoids. Topical corticosteroids can be used for more severe cases, and should generally be limited to 2-week courses or used 1 to 3 times per week to minimize risk of atrophy and other side effects. Benzoyl peroxide can be used alone or as a fixed combination with an antibiotic, and is recommended after shaving. The potential to bleach shirt collars is a possible limitation that should be conveyed to the patient. In a multicenter, double-blind, vehicle-controlled study, benzoyl peroxide 5%/clindamycin 1% gel demonstrated significant reductions in combined papule and pustule counts.
      • Cook-Bolden F.E.
      • Barba A.
      • Halder R.
      • et al.
      Twice-daily applications of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae.
      Topical retinoids (tretinoin, adapalene, or tazarotene) are recommended nightly, and are useful for improving both the clinical lesions of PFB
      • Perry P.K.
      • Cook-Bolden F.E.
      • Rahman Z.
      • et al.
      Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
      • Kligman A.M.
      • Mills Jr., O.H.
      Pseudofolliculitis of the beard and topically applied tretinoin.
      • Coley M.K.
      • Alexis A.F.
      Managing common dermatoses in skin of color.
      and the associated postinflammatory hyperpigmentation.
      • Bulengo-Ransby S.M.
      • Griffiths C.E.
      • Kimbrough-Green C.K.
      • et al.
      Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients.
      Postinflammatory hyperpigmentation can be a significant sequela in PFB, and can cause as much distress to the patient as do the primary lesions of PFB. Thus, bleaching preparations including hydroquinone can also be used for secondary postinflammatory hyperpigmentation.
      For cases resistant to topical therapy or for patients with PFB who prefer a longer-term clean-shaven appearance, laser hair removal is an effective option.
      • Weaver 3rd, S.M.
      • Sagaral E.C.
      Treatment of pseudofolliculitis barbae using the long-pulse Nd:YAG laser on skin types V and VI.
      • Smith E.P.
      • Winstanley D.
      • Ross E.V.
      Modified superlong pulse 810 nm diode laser in the treatment of pseudofolliculitis barbae in skin types V and VI.
      • Ross E.V.
      • Cooke L.M.
      • Timko A.L.
      • et al.
      Treatment of pseudofolliculitis barbae in skin types IV, V, and VI with a long-pulsed neodymium:yttrium aluminum garnet laser.
      Using lasers that are safe for the patient’s skin type is paramount, as the risk of epidermal injury is greater in higher Fitzpatrick skin phototypes (SPT).
      • Alexis A.F.
      Lasers and light-based therapies in ethnic skin: treatment options and recommendations for Fitzpatrick skin types V and VI.
      Given that epidermal melanin acts as a competing chromophore in individuals with higher SPT, longer-wavelength lasers such as the diode (800–810 nm) and neodymium:yttrium aluminum garnet (Nd:YAG 1064 nm) lasers are preferred for men of African ancestry with high SPT. The 1064-nm Nd:YAG laser has the safest profile for this patient population and therefore is strongly preferred.
      • Alexis A.F.
      Lasers and light-based therapies in ethnic skin: treatment options and recommendations for Fitzpatrick skin types V and VI.
      Combining topical eflornithine hydrochloride 13.9% cream (to slow down hair growth) along with long-pulsed 1064-nm Nd:YAG laser hair removal has been shown to be more effective than laser hair removal alone.
      • Xia Y.
      • Cho S.
      • Howard R.S.
      • et al.
      Topical eflornithine hydrochloride improves the effectiveness of standard laser hair removal for treating pseudofolliculitis barbae: a randomized, double-blinded, placebo-controlled trial.

      Folliculitis keloidalis nuchae

       Epidemiology

      FKN, also known as acne keloidalis nuchae, is a follicular disorder primarily seen in men of African ancestry with Afro-textured hair. However, it may rarely also be seen in women; the ratio of affected men to affected women is 20:1.
      • Kelly A.P.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      • Dinehart S.M.
      • Tanner L.
      • Mallory S.B.
      • et al.
      Acne keloidalis in women.
      In an epidemiologic study by Khumalo and colleagues,
      • Dadzie O.E.
      • Petit A.
      • Alexis A.F.
      Ethnic dermatology: principles and practice.
      FKN was diagnosed in 4.7% of South African boys in the last year of school, in 10.5% of adult men, and 0.3% of adult women. In a study by Adegbidi and colleagues,
      • Adegbidi H.
      • Atadokpede F.
      • do Ango-Padonou F.
      • et al.
      Keloid acne of the neck: epidemiological studies over 10 years.
      FKN accounted for 0.7% of all dermatology consultations at a university hospital in Benin, while Salami and colleagues
      • Salami T.
      • Omeife H.
      • Samuel S.
      Prevalence of acne keloidalis nuchae in Nigerians.
      reported a prevalence of 9.4% of dermatology consultations at a Nigerian university hospital. FKN occurs in 0.5% of African Americans.
      • Ogunbiyi A.
      • George A.
      Acne keloidalis in females: case report and review of literature.
      Men often attribute the beginning of FKN to an infection from unclean barber instruments,
      • Khumalo N.P.
      • Gumedze F.
      • Lehloenya R.
      Folliculitis keloidalis nuchae is associated with the risk for bleeding from haircuts.
      although this has not been substantiated in published studies. Khumalo and colleagues
      • Dadzie O.E.
      • Petit A.
      • Alexis A.F.
      Ethnic dermatology: principles and practice.
      reported an association between FKN and bleeding from haircuts. The papules of FKN may be injured during the hair-cutting process because of the force required to perform haircuts on patients with tightly coiled hair texture.
      • Khumalo N.P.
      Folliculitis keloidalis nuchae, bleeding from haircuts, and potential HIV transmission.
      In the setting of shared, unsterilized hair clippers, transmission of human immunodeficiency virus and other blood-borne diseases are a risk.
      • Khumalo N.P.
      Folliculitis keloidalis nuchae, bleeding from haircuts, and potential HIV transmission.

       Pathogenesis

      The etiology of FKN remains incompletely understood.
      • Rodney I.J.
      • Onwudiwe O.C.
      • Callender V.D.
      • et al.
      Hair and scalp disorders in ethnic populations.
      FKN usually occurs in men with frequent and close haircuts.
      • Khumalo N.P.
      • Jessop S.
      • Gumedze F.
      • et al.
      Hairdressing is associated with scalp disease in African schoolchildren.
      It may also occur in women who shape the hair of the posterior neck with a razor.
      • Khumalo N.P.
      • Gumedze F.
      • Lehloenya R.
      Folliculitis keloidalis nuchae is associated with the risk for bleeding from haircuts.
      Shapero and Shapero
      • Shapero J.
      • Shapero H.
      Acne keloidalis nuchae is scar and keloid formation secondary to mechanically induced folliculitis.
      hypothesized that FKN is initiated by a mechanically induced folliculitis that becomes extensive enough to result in scar formation. Based on a histopathologic study, Sperling and colleagues
      • Sperling L.C.
      • Homoky C.
      • Pratt L.
      • et al.
      Acne keloidalis is a form of primary scarring alopecia.
      argue that FKN is a primary cicatricial alopecia that is not causally associated with ingrown hairs or bacterial infection.
      Reported contributory factors to FKN include trauma, chronic irritation, seborrhea, infection, and elevated testosterone levels.
      • Khumalo N.P.
      • Gumedze F.
      • Lehloenya R.
      Folliculitis keloidalis nuchae is associated with the risk for bleeding from haircuts.
      • George A.O.
      • Akanji A.O.
      • Nduka E.U.
      • et al.
      Clinical, biochemical and morphologic features of acne keloidalis in a black population.
      Sources of mechanical irritation that may exacerbate or potentially contribute to the development FKN include friction from high-collared shirts, sports helmets, and other garments or equipment.
      • Khumalo N.P.
      • Gumedze F.
      • Lehloenya R.
      Folliculitis keloidalis nuchae is associated with the risk for bleeding from haircuts.
      • Shapero J.
      • Shapero H.
      Acne keloidalis nuchae is scar and keloid formation secondary to mechanically induced folliculitis.
      George and colleagues
      • George A.O.
      • Akanji A.O.
      • Nduka E.U.
      • et al.
      Clinical, biochemical and morphologic features of acne keloidalis in a black population.
      found that 58% of Nigerian patients with FKN reported using a uniquely shaped comb, called an Afro wooden or plastic comb, frequently referred to as an Afro pick in the United States. The investigators pointed out that while using this comb, users often mechanically scrape the surface of the scalp.
      • George A.O.
      • Akanji A.O.
      • Nduka E.U.
      • et al.
      Clinical, biochemical and morphologic features of acne keloidalis in a black population.
      The development of FKN in a black man following an episode of zoster on the scalp has been reported.
      • Bellavista S.
      • D'Antuono A.
      • Gaspari V.
      • et al.
      Acne keloidalis nuchae on herpes zoster scar in an HIV patient: isotopic response or not?.
      Keloidal plaques in patients with FKN may not develop on any other part of the body except for the occipital scalp. FKN patients, unlike patients with multiple keloids on the body, often do not have a personal or family history of keloids.
      • Khumalo N.P.
      • Gumedze F.
      • Lehloenya R.
      Folliculitis keloidalis nuchae is associated with the risk for bleeding from haircuts.
      Understanding why keloidal plaques are site restricted in FKN may provide clues to the pathogenesis of FKN and keloids.
      The histology of FKN usually consists of chronic perifollicular inflammation and destruction of hair follicles.
      • Shapero J.
      • Shapero H.
      Acne keloidalis nuchae is scar and keloid formation secondary to mechanically induced folliculitis.
      Features of transepithelial hair elimination similar to those found in perforating disorders, including granuloma annulare, reactive perforating collagenosis, elastosis perforans serpiginosa, and chondrodermatitis nodularis chronica helicis, have also been described.
      • Goette D.K.
      • Berger T.G.
      Acne keloidalis nuchae. A transepithelial elimination disorder.
      In a study of Nigerian patients by George and colleagues,
      • George A.O.
      • Akanji A.O.
      • Nduka E.U.
      • et al.
      Clinical, biochemical and morphologic features of acne keloidalis in a black population.
      the nape of the neck/occipital scalp was found to have an increased (almost double) number of mast cells compared with the anterior scalp. Moreover, dermal capillary dilation was more profound on the nape of the neck.
      • George A.O.
      • Akanji A.O.
      • Nduka E.U.
      • et al.
      Clinical, biochemical and morphologic features of acne keloidalis in a black population.
      The large number of mast cells in this location may contribute to a pruritic sensation prompting rubbing and manipulation of the skin.
      • Shapero J.
      • Shapero H.
      Acne keloidalis nuchae is scar and keloid formation secondary to mechanically induced folliculitis.
      Genetic predisposition may also influence the density of mast cells in the scalp.
      • Shapero J.
      • Shapero H.
      Acne keloidalis nuchae is scar and keloid formation secondary to mechanically induced folliculitis.

       Clinical Features

      FKN is characterized by fibrotic papules on the occipital scalp, typically involving the nape of the neck (Fig. 6). Pustules and/or crusted papules can also be observed, especially when secondary infection occurs (Fig. 7). Severe secondary infections can result in abscess formation. Pruritus is common, and patients frequently admit to scratching or rubbing the affected areas. In severe or long-standing cases the papules may coalesce into a large, hairless fibrotic plaques or nodules. Tufted hairs (multiple hair shafts emerging from a single follicular opening) may also be present.
      • Coley M.K.
      • Kelly A.P.
      • Alexis A.F.
      Pseudofolliculitis barbae and acne keloidalis nuchae.
      • Dadzie O.E.
      • Petit A.
      • Alexis A.F.
      Ethnic dermatology: principles and practice.
      FKN can be disfiguring and may adversely affect self-esteem.
      Figure thumbnail gr6
      Fig. 6Folliculitis keloidalis nuchae with characteristic involvement of the posterior scalp and nape of neck.
      Figure thumbnail gr7
      Fig. 7Folliculitis keloidalis nuchae with secondary infection. Note crusted papules on the occipital scalp.

       Management

      The first step in the management of FKN is initiating preventive measures to minimize disease progression or exacerbation. Such measures include avoidance of mechanical irritation from shirt collars, hats, short haircuts, and self-manipulation; and the use of topical antimicrobial cleansers (eg, chlorhexidine or povidone iodine) to prevent secondary infection.
      Mild to moderate cases of FKN can be improved with the use of potent and ultrapotent topical corticosteroids. Topical therapies are generally sufficient when the papules are 3 mm or smaller and no nodules are present. To prevent atrophy and other side effects of corticosteroids, an alternating 2-week cycle (ie, 2 weeks on, 2 weeks off) of the steroid is a useful approach. In a study by Callender and colleagues,
      • Callender V.D.
      • Young C.M.
      • Haverstock C.L.
      • et al.
      An open label study of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of mild to moderate acne keloidalis.
      alternate 2-week cycles of clobetasol propionate 0.05% foam twice daily for 8 weeks (followed by 4 weeks of betamethasone valerate 0.12% foam twice daily if lesions persisted) demonstrated significant decreases in papule/pustule counts at week 12. Topical clindamycin gel or foam can also be used in conjunction with topical corticosteroids, especially when pustules are present. For larger papules and plaques, 20 to 40 mg/mL triamcinolone acetonide intralesionally should be added to the regimen. Oral doxycycline or minocycline are useful for extensive cases because of their anti-inflammatory and antimicrobial effects (in cases of secondary infection).
      Surgical excision can be considered for severe cases of FKN that are resistant to medical therapy, especially when large (eg, ≥3 cm) fibrotic plaques or nodules are present. Recommended techniques for surgical management of FKN include excising a horizontal ellipse that involves the posterior hairline and extends to the subcutaneous fat, followed by either second-intention healing
      • Glenn M.J.
      • Bennett R.G.
      • Kelly A.P.
      Acne keloidalis nuchae: treatment with excision and second-intention healing.
      • Beckett N.
      • Lawson C.
      • Cohen G.
      Electrosurgical excision of acne keloidalis nuchae with secondary intention healing.
      or primary closure.
      • Gloster Jr., H.M.
      The surgical management of extensive cases of acne keloidalis nuchae.
      Excision by carbon dioxide laser
      • Kantor G.R.
      • Ratz J.L.
      • Wheeland R.G.
      Treatment of acne keloidalis nuchae with carbon dioxide laser.
      and electrosurgery
      • Beckett N.
      • Lawson C.
      • Cohen G.
      Electrosurgical excision of acne keloidalis nuchae with secondary intention healing.
      (followed by second-intention healing) have also been reported. Published studies with long-term follow-up are currently lacking and, therefore, there is a paucity of data on recurrence rates from surgical excision of FKN. Notwithstanding this limitation, the rates of recurrence after excision of FKN appear to be low, in contrast to those associated with keloid excisions.
      Laser hair removal can be considered as an alternative or adjunct to conventional therapies.
      • Shah G.K.
      Efficacy of diode laser for treating acne keloidalis nuchae.
      • Esmat S.M.
      • Abdel Hay R.M.
      • Abu Zeid O.M.
      • et al.
      The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study.
      In a study of 16 patients with FKN who underwent 5 sessions of laser hair removal with the long-pulsed Nd:YAG laser, significant reductions in papule count, plaque count, and plaque size were observed.
      • Esmat S.M.
      • Abdel Hay R.M.
      • Abu Zeid O.M.
      • et al.
      The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study.

      Summary

      PFB and FKN are potentially disfiguring follicular disorders that are primarily seen in men of African ancestry who have Afro-textured hair. Recent advances have brought prevention strategies and effective treatment within reach for most patients. Modification of grooming practices in combination with the appropriate use of both pharmacologic and procedural interventions is generally effective in controlling these diseases. Notwithstanding recent advances, PFB and FKN remain therapeutically challenging, relapses are common, and potential barriers to care exist (eg, limited access to laser hair removal, the need for frequent office visits, and considerable costs of treatment). Further research is warranted to better elucidate the mechanisms of disease, optimize treatment outcomes, and, ultimately, improve the quality of life of patients with these disorders.

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