Enhanced management of folliculitis barbae: New insights and strategies
Changes in grooming practice, washes, retinoids, and potentially laser Tx all contribute to improved outcomes (Issue #240, 1,600 words, 8 minutes)
Folliculitis barbae, previously known as pseudofolliculitis barbae, primarily affects men with Afro-textured hair, Dr. Renée A. Beach told delegates at the 10th annual Skin Spectrum Summit on Oct. 5 in Toronto. Treating folliculitis barbae involves a multi-pronged approach, she said.
Dr. Beach is a dermatologist practicing medical and cosmetic dermatology in Toronto.
Dr. Beach used the example of a male patient with Black skin who regularly developed papules from shaving his neck. The patient had fibrosis and dyspigmentation and would likely end up with scarring. This condition, folliculitis barbae, can be caused by both exogenous factors, such as shaving—often dictated by cultural norms or employer expectations, and endogenous factors, such as curvature of the hair follicle and kinky hair shafts. The patient develops inflammation of the hair follicle, which can progress to fibrosis and may even lead to sycosis barbae, which is pustular and needs to be treated with antibiotics.
In Afro-textured hair, the hair is kinky, and the actual follicle is curved, said Dr. Beach. When hair grows from the follicle after it has been cut short, it may grow into the walls of the pilosebaceous unit.
Dr. Beach said that treating folliculitis barbae is multi-pronged, with the first step addressing grooming. She recommends that patients use a single-blade razor or trimmer that is not set to the shortest level and use short strokes in a single direction. She also recommended only shaving once per week and, between shavings, washing with salicylic acid or with alpha or beta hydroxy acid.
The next step is prescription therapy, such as retinoids, said Dr. Beach. These help to shed keratinocytes and increase epidermal cell turnover. She recommends that patients initially use the therapy nightly if they can tolerate it. As the patients taper off or in the maintenance phase, they may reduce retinoid use to three or four nights a week. Retinoids will also smooth papules and reduce hyperpigmentation. Dr. Beach said she prescribes tazarotene lotion for patients with public medication insurance or who are under 25 years of age and use OHIP+.
For patients who require rescue therapy, Dr. Beach said she prescribes a combination of 5% benzoyl peroxide and 1% clindamycin two to three nights a week when needed. However, this treatment may cause irritateay stain linens.
Dr. Beach said procedural therapy, such as lasers, is the last prong of the treatment. She uses a 1,064 nm Nd:YAG laser, with treatments every four to six weeks until clearance. She cautioned that patients will require quarterly maintenance sessions.
Bottom Line: Folliculitis barbae primarily affects men with Afro-textured hair and can be caused by both exogenous and endogenous factors. It is treated by first adjusting grooming practices such as shaving. The next step is prescribing topical retinoids, which help shed keratinocytes and increase epidermal cell turnover, smoothing papules and reducing hyperpigmentation. For rescue therapy, a combination of 5% benzoyl peroxide and 1% clindamycin can be used two to three nights a week when needed. The final step may be procedural therapy using a laser.
From the literature on hair and scalp dermatology in skin of colour
Concurrent lichen planopilaris and female androgenic alopecia in skin of colour: A case series
This case series details three cases of concurrent lichen planopilaris (LPP) and female androgenic alopecia (FAGA) in skin of colour.
Gross examination of all cases revealed mild to moderate hair density thinning of the temporal and frontal scalp. Physicians performed trichoscopy in all three cases before biopsy. The temporal scalp of each patient showed diffuse hair follicle miniaturization with minimal terminal hairs and brown follicular halos, and all findings were consistent with FAGA. However, upon inspection of the frontal scalp, each case revealed findings associated with scarring alopecia, including scale, erythema, peripilar casts, and follicle miniaturization.
In the first two cases, the physicians took two punch biopsies, one from the temporal scalp and one from the frontal scalp. The temporal biopsy revealed FAGA, and the frontal biopsy revealed LPP arising in a background of AGA. In the third case, they only biopsied the frontal scalp, which showed LPP in a background of FAGA. All three cases received the same treatment regimen: clobetasol 0.05% solution and minoxidil 5% foam/solution topically for treatment of FAGA and monthly intralesional triamcinolone acetonide for treatment of the LPP.
In their conclusion, the authors say this report suggests the importance of total scalp dermoscopy and the need for biopsies in areas with varying dermoscopy findings as opposed to areas with the most significant hair loss.
Baseline trichoscopic values for afro-textured hair in Indigenous South Africans show lower density and unique features
This cross-sectional study involved 122 South Africans of both genders of African ancestry (mean age 20.9±3.3 years) with natural afro-textured hair. Researchers sought to establish trichoscopic norms, capturing standard images, one overview, and five microimages (one 20× and four 50× magnifications) with the FotoFinder Medicam1000V2 videodermoscope. They also assessed hair density (HD; N/cm2); hair shaft thickness (HST; μm); the proportion of thin, mid, and thick hairs (%); cumulative hair thickness (mm/cm2); and follicular units (FU; N/cm2).
Researchers found the average HD was 139.1±33.88 hairs/cm2 with significant variations across different scalp areas. The average hair thickness was 62.59±8.45 μm, with the frontal scalp showing the greatest HST, the proportion of thick hairs, cumulative hair thickness, and FU densities; the temporal had the greatest proportion of thin hairs, whereas the occipital showed the highest proportion of triple hair FU. Male participants exhibited significantly greater average hair thickness, thick hairs, and double and triple FU. In contrast, females had higher cumulative hair thickness density, more thin and intermediate hairs, and more single follicular units.
Surgical management of acne keloidalis nuchae: A systematic review of outcomes and techniques
Investigators evaluated the outcomes of surgical treatment of acne keloidalis nuchae (AKN), including recurrence rates, complications, and patient satisfaction.
Researchers conducted a systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines across four databases, including studies focusing on surgical interventions for AKN. They extracted data on demographics, surgical techniques, complications, and outcomes.
Sixteen studies comprising 99 patients met the inclusion criteria. The authors found that AKN predominantly affected African American males (86.66%). Surgical techniques varied, with primary closure (58.16%) and secondary intention healing (28.42%) being the most common. Recurrence occurred in 19.19% of cases but could be managed conservatively. Researchers noted hypertrophic scarring in 11.43%, most commonly after primary closure. Infection rates were low (3.13%); however, topical and oral antibiotics were often part of postoperative treatment. Patient satisfaction and cosmetic outcomes were universally positive across studies despite methodological variability.
The authors conclude that surgical excision is an effective treatment for AKN. While recurrence still occurs, it can be managed conservatively. Additionally, hypertrophic scarring remains a challenge for patients with AKN. Infection rates were low, and high patient satisfaction was often reported. Standardized methodologies and multicentre studies are needed to optimize surgical approaches and long-term outcomes.
At the intersection of skin and society
Recent findings by Consumer Reports show potentially dangerous chemicals present in synthetic braiding hair products frequently used by Black women and girls.
Published online, the report notes that attachable braids and faux locs are deeply rooted in Black culture and are frequently worn by celebrities.
Black women are the primary users of these products, notes the consumer protection group, and people of African descent are the largest group of consumers of hair wigs and extensions. In 2023, the U.S. market for these products was valued at $2.79 billion and is expected to reach $6.34 billion by 2029.
However, some consumers have reported health issues arising from synthetic braids. Part of the concern with these products is the duration of exposure—synthetic braids are typically worn for six to eight weeks.
One of the most immediate and evident adverse effects of synthetic braiding hair is on the skin. Symptoms include redness, swelling, and rashes on the scalp, neck, or face, generally due to allergic reactions to dyes or other colouring in the synthetic hair.
This complaint is commonly heard from braid wearers, especially after installation. Dermatologist Dr. Chesahna Kindred told Consumer Reports that she has had patients concerned that they were allergic to their synthetic hair braids. “It would look like contact dermatitis, which is when the scalp is inflamed, it’s red, the patient complained about an itching or burning sensation, and we would have to treat it with a cortisone,” she says. Dr. Kindred operates a practice in Stratfield, Conn., and is a Past Chair of the U.S. National Medical Association, Dermatology Division.
Scientists working for Consumer Reports tested 10 popular synthetic braiding hair products for heavy metals and volatile organic compounds (VOCs) to better understand how much risk synthetic braiding hair poses. Their top findings include:
Carcinogens, or chemicals that may cause cancer, were detected in 100% of the samples
Lead was detected in nine of 10 products, in amounts that exceeded the level deemed safe by experts
Other VOCs, including acetone, were detected in all products
More information on the products tested, the methodologies used, and consumer guidance is available in the report.
This week
March 31 is National Indigenous Languages Day in Canada
April is Sikh Heritage Month in Canada
April is National Stress Awareness Month in the U.S.
Something to think about in the week ahead . . .
—Mary Tyler Moore, (1936 - 2017) U.S. actress
Next week
New findings from researchers in the U.S. and Pakistan show that fractional CO2 laser therapy has promise in managing mature hypertrophic burn scars in patients with skin of colour.
Indigenous Skin Spectrum Global Summit this Saturday
There is still time to register for the first Indigenous Skin Spectrum Global Summit, which will be held in Montreal on April 5, 2025.
The 2025 Indigenous Skin Spectrum Global Summit is dedicated to improving the cultural competence of healthcare providers worldwide. Our world-renowned faculty will provide practical and up-to-date clinical information on the latest and best research in the context of Indigenous, circumpolar, and rural communities.
In the video below, Summit chair Dr. Rachel Asiniwasis (Regina) invites physicians from around the world to learn more about the unique dermatologic challenges facing Indigenous, rural, and circumpolar populations worldwide.
Whether attending in-person or virtually, delegates will hear experts from around the world provide insights on how physicians can support equitable health for these populations.
Don’t miss an informative talk by Dr. Archana Kakadekar, an anatomical pathologist specializing in dermatopathology and breast pathology, exploring the latest research on dermatopathology in skin of colour. Dr. Kakadekar is based in Saskatoon.
More details on the Global Summit are at this link.
If you enjoy Skin Spectrum Weekly, why not check out the Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Dr. Ruth Ann Vleugels (Boston) describes emerging treatments for dermatomyositis associated with lupus.
Drs. Charles Lynde (Markham, Ont.), Fiona Lovegrove (London, Ont.), Julien Ringuet (Quebec), and Kerri Purdy (Halifax) review new dermatologic therapies to watch in 2025.
Dr. Susan Poelman (Calgary) summarizes current research into hidradenitis suppurativa treatments and discusses why physicians should be optimistic about the future of managing this disease.
Plus regular features, including the popular column “Vender on Psoriasis” by dermatologist Dr. Ron Vender.
You can read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary subscription or to request a sample copy, please email health@chronicle.org with your contact information.
The Women in Dermatology e-newsletter updates readers with new findings concerning dermatologic issues affecting women and the female dermatologists who care for them. Read the current issue here.
Season three of the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode five, Dr. Vender discusses whether vitamin D influences psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
And if you’re looking for a web destination for all things derm, visit derm.city, “Where Dermatology Lives.” Please like, rate, review, and share it with your colleagues.