Case of the Month

Case of the Month

Necrobiosis Lipoidica Diabetecorum

This 25 year old African-American man developed these bumps on his chest after preparing for a trip to Florida (with college buddies) involving lots of planned “beach time”. He previously had a significant amount of hair on his chest.

What's Your Diagnosis?

Diagnosis:

Pseudofolliculitis Barbae (PFB).

Although not a common location for PFB, the etiology is the same as the neck and cheeks; these razor bumps developed after using a manual razor to very closely shave off all the hair on his chest.

Discussion:

Pseudofolliculitis, as the name denotes, is not a true folliculitis, but results from hairs that, instead of growing straight out of follicles, coil, curve, and penetrate the skin. In brief, pseudofolliculitis is a kind of “foreign body rea

ction” in which the “ingrown hair” acts as a foreign body that induces, in stages, suppurative, granulomatous, and fibrosing inflammation. When an abscess is present within the epidermis, it presents itself clinically as a pustule. Not surprisingly, the pustules of psuedofolliculitis are intraepidermal, in contrast to those of folliculitis which are intra-infundibular. When an abscess of psuedofolliculitis is present around a hair within the dermis, the lesion is seen clinically as an inflamed papule.


Here is a handout I give to my patients; please feel free to reprint it and use as you may need.

Dr. Crutchfield’s PFB Treatment Tips

Razor bumps look and feel like pimples, but they are actually the result of ingrown hairs. The medical term for this condition is Pseudo-folliculitis barbae (PFB).

PFB Hair Grown

Extra-Follicular Penetration

Ideal Follicular Condition of Hair

Ideal Hair Trim & Growth

Trans-follicular penetration

Trans-Follicular Penetration

What causes razor bumps?

Hair grows inside tubes in the skin called “follicles.” When shaved, the tip of the hair is left with a sharp point. As curly hair grows, this sharp tip may curve back and pierce the skin. The medical term for this cause of PFB is “extrafollicular penetration.”

Razor bumps can also form when shaving too close to the skin causes the whiskers to be clipped off below the skin surface. This allows the hair to penetrate the side of the follicle instead of following its normal path to the skin surface. This can occur more often with curly hair. The medical term for this cause of PFB is “transfollicular penetration.”

The body treats all ingrown hairs just as it would splinter or any other foreign object by producing an inflammatory pimple- like bump. Often, if the condition occurs over an extended period of time, the skin will respond by producing unsightly dark spots at the sites of the PFB pumps. Unfortunately, these dark spots can take many months to fade. Since most African-American men have curly, course hair and curved follicles, they frequently suffer from razor bumps. This is also true for people of Mediterranean descent. It should be noted that razor bumps can affect anyone who has curly hair or, who has hair follicles oriented at oblique angles to the skin surface which makes it easier for the Sharp hair tips to re-enter the skin.

The key to controlling PFB to minimize hair re-entry back into the skin(and subsequent inflammation) by reducing the sharpness of the hair tip and to leave hair at the appropriate length after shaving.

What to do about razor bumps:

The best therapy is to avoid shaving and let the beard grow. However, this is not always a practical solution. If you do shave, the following step-by-step program is recommended:
(It should be noted that if your doctor feels that your condition is extreme, you should let your beard grow out for several weeks before proceeding. As the hair lengthens, the shafts will act like miniature “springs” and eventually “pop free.” Your doctor may even prescribe a short course of antibiotic pills. Your doctor will tell you when to begin the anti-PFB shaving program.

TREATMENT STEPS:

#1
Wet your beard with warm water to soften the hair. The best way to accomplish this is to take a shower before shaving. Make sure that your beard hair is in contact with the water for at least two minutes. This will fully hydrate your hair. Hydrated haircuts more easily and leaves a hair tip that is not as sharp. This will decrease the chance for re-entering the skin. (See “ideal condition”).

#2
Use a soft bristled toothbrush, in a circular motion on the beard area to dislodge any hair tips that are beginning to pierce the skin. This should be done twice per day before shaving and at bedtime. If approved by your doctor, you may even use a sterile needle cleaned with rubbing alcohol are pointed to pick, to dislodge any particularly stubborn tips failure to dislodge any tips attempting to re-enter the skin will cause “extrafollicular” razor bumps.

#3
Use an adjustable electric razor for shaving. Make sure to get one that has adjustable blade settings. Shave at the setting that leaves hair the longest to prevent “transfollicular” razor bumps.

#4
Use Vaniqa ™ lotion twice daily. Vaniqa is a product that requires a prescription from your doctor. Vaniqa will make the hair grow very slowly, so less grooming is required which means less overall irritation.

#5
After shaving, ask your dermatologist if you should use a very mild (class VI) anti-inflammatory lotion. This will minimize inflammation and irritation.

#6
Always use a “collar extender” whenever wearing neckties to prevent excess friction and pressure from worsening the PFB condition on the neck and collar area. These can easily be found on Amazon.com.

#7
For cleansing purposes, you should always use a mild soap such as Vanicream cleansing bar, Dove unscented, Olay, Purpose, Basis or Cetaphil.

#8
If dark spots are a problem, talk to your dermatologist about using a lightening cream such as Lytera or TriLuma.

#9
Additionally, if one is using a lightening cream, a good sunscreen must be applied twice daily, once in the morning and one other time. Using a lightening cream without sunscreen is like walking up an escalator that is moving down – tough to make any progress.

It may take a few days to several weeks for your condition to improve. Sometimes it can even take a couple of months to see improvement. Stay with the program and don't give up.

The goal is to not necessarily have” perfect” skin but to significantly improve the current condition of your skin. "Don't let perfection be the enemy of Very Good." Many patients do not experience extremely satisfying results when using this system. In extreme cases that are not responding, laser hair removal can be considered with great caution.

It is also important to note that whenever you have inflammation of the skin, your skin can react by producing dark spots. If the inflammation is removed, the dark spots will fade away with time. This may take several weeks or even months. The best way to treat dark spots to prevent them from coming in the first place.

Hopefully, that's what this skin program will do for you!


Reference:

A CLINICAL ATLAS OF 101 COMMON SKIN DISEASES
With Histopathologic Correlation
A. BERNARD ACKERMAN, HELMET KERL, JORGE SANCHEZ, YING GUO, ANGELIKA HOFER, PAUL KELLY, TETSU KIMURA, GIOVANNI BORRONI,CHARLES CRUTCHFIELD, VOLKER STEINKRAUS, WOLFGANG WEYERS


Charles Crutchfield III M.D. Eagan Dermatologist

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