Michael T Tshudy, Sunghun Cho, Pseudofolliculitis Barbae in the U.S. Military, a Review, Military Medicine, Volume 186, Issue 1-2, January-February 2021, Pages e52–e57, https://doi.org/10.1093/milmed/usaa243
Navbar Search Filter Mobile Enter search term Search Navbar Search Filter Enter search term SearchPseudofolliculitis barbae (PFB), also known as ingrown hairs commonly results from adherence to military grooming standards in those who have curly facial hair. Many patients respond to specific grooming techniques or topical medications but severe cases often warrant restrictions on shaving or laser therapy. The treatment of PFB is challenged not only by grooming standards but also evolving readiness requirements. More recently, the Navy discontinued permanent restrictions on shaving because of concerns for poor gas mask fitting. The goal of this review is to outline the history of PFB in the military, describe current policies, and offer a more uniform approach to treating PFB in the military. We also discuss challenges that surround the management of PFB in the Armed Forces.
Materials and MethodsWe conducted a systematic review of the literature utilizing PubMed to identify both current and past management and discussion of PFB in both civilian and military settings. We also performed an internet search to identify pertinent military regulations and history of PFB within the Armed Forces. A query of TRICARE, the health care program for the U.S. Department of Defense Military Heath System, was also performed to assess civilian-referred laser treatment for Active Duty service members.
PFB has a long history in the military dating back to World War I, when shaving was enforced not only to ensure good personal hygiene and to foster good order and discipline but also to ensure gas masks would seal in the event of a chemical attack. The management of PFB has presented a challenge in the military and even led to a social uproar in the 1970s. Policy changes in the military regarding shaving limitations, or profiles, have historically influenced how PFB is managed, but the basic tenets remain the same. Grooming techniques and topical medications can be effective in treating mild-to-moderate disease, but more severe cases of PFB respond best to laser therapy. Limitations on shaving remain an important part of management, especially during flares of the disease and while initiating therapy. Long-term shaving profiles may be needed for treatment-resistant cases. The impact of the Navy’s recent policy on PFB is also discussed.
ConclusionsPseudofolliculitis Barbae is a prevalent skin disease in the Armed Forces. A better understanding of the disease and patients’ individual needs by the health care provider and commander is paramount.
Pseudofolliculitis barbae (PFB), also referred to as “razor bumps,” “shaving bumps” or “ingrown hairs,” is a common inflammatory condition of the face and neck caused by shaving in predisposed individuals who have naturally curly hair. 1, 2 Papules, pustules, and nodules often characterize this inflammatory foreign body reaction that occurs to the patient’s own hair. Pseudofolliculitis barbae affects around 45% of African American Service Members, a much lower percentage of Hispanics and about 3% of Caucasians. 3, 4 Although elective removal of hair by shaving, plucking, waxing elsewhere on the body such as the underarm and pubic skin and on the chin can also cause PFB, this review will focus on service-related PFB brought forth by military grooming standards.
Grooming regulations in the military have changed significantly over the years. The regulations were established as a means of standardization and to foster good order and discipline but since World War I, with the beginning of chemical warfare, shaving has been enforced also as a matter safety—a way of ensuring gas masks would seal in the event of a chemical attack. 5
PFB was originally discussed in a 1922 report by Dr. William Dubreuilh, but it was not until 1956 that a study by Drs. Strauss and Kligman closely investigated the association of PFB with shaving in a landmark paper and also coined the popular term. 6, 7
In the U.S. military, PFB has been the justification for a “shaving waiver” (also known “shaving profile” in the Army and Air Force; “shaving chit” in the Navy and Marine Corps) that allows servicemen to deviate from grooming standards. Unfortunately, because some service members are unfamiliar with the condition, a stigma can result from the difference in grooming appearance amongst servicemen within a unit. Although PFB is the most common dermatologic complication of military grooming standards, it is not the only one. A recent article discussed other skin conditions related to grooming including acne keloidalis nuchae, dissecting cellulitis of the scalp, folliculitis decalvans, traction alopecia, and keloids. 8
Around the 1970s, the management of PFB led to significant distress for black service members and social uproar. 9–11 In fact, 5.9% of dermatology consults were for PFB during the Vietnam War. 12 This eventually led to the creation of military PFB clinics, improved guidelines for service members and commanders, and exceptions to the grooming standards by issuing exemptions to shaving. The institution of new treatment and management guidelines that included exemptions from shaving, led to a decline in dermatologic referrals to 1.8% in Operation Iraqi Freedom and to less than 1% in other recent deployments. 12 The Navy has had arguably the most amount of administrative changes regarding beard growth over the years. In 1970, under the leadership of Admiral Elmo R. Zumwait, it was the only service to authorize the elective wearing of beards by with the virtual elimination of PFB as a medical-administrative problem. 11 Since then, it has adopted grooming standards similar to the other services. The Navy recently discontinued permanent shaving profiles because of concerns of ineffective mask seals from beard growth. 13 To prevent a potential overload of laser capacities at the Military Treatment Facilities (MTFs), Tricare released a streamlined process for obtaining laser therapy at civilian facilities for service members afflicted with PFB in late 2019. 14
Department of Defense Instruction 6130.03 classifies PFB as a disqualifying but waivable condition for initial appointment, enlistment or induction into military service.
The cause of PFB is primarily associated with the curved shape of the hair follicle and tightly curled hair structure but can be associated with an additional genetic predisposition. Pseudofolliculitis barbae is most commonly triggered by grooming techniques—most notably shaving. 15 Upon shaving, the end of the hair is left closer to the skin surface and becomes sharper. As the hair grows out it can curve into the skin and pierce the epidermis and dermis. Alternatively, the hair can penetrate internally, by way of the hair follicle. 1 The latter occurs more commonly with pulling the skin taut during shaving which leads the hair to retract beneath the surface of the skin. 1, 2, 9 Irritation contact dermatitis secondary to shaving can cause thickening of the skin and may be an additional risk factor in causing PFB. 16 A genetic risk factor, independent of curled hair, also exists, involving a polymorphism of a keratin specific to the hair follicle (KRT75), which occurs predominately in black individuals. 2 this polymorphism leads to a weakening of the cytoskeleton and confers a 6-fold increased risk of developing PFB. 15 Because of the pathogenesis, PFB is much more common in the military and in African Americans with tightly curled facial hair.
PFB presents 24 to 48 hours after a close shave with erythematous papules or pustules and varying degrees of irritation and redness. Although the diagnosis is often straight forward and made on gross visual inspection, dermoscopy may be used to better visualize the hairs imbedded into the skin. The most common complication of PFB is hyperpigmentation as a post-inflammatory response seen more commonly in darker skin types (Fig. 1). More severe but less common complications include scarring and keloids. Secondary bacterial infection can be seen with active PFB. Culture of pustules and papulopustules in PFB usually results in normal skin flora bacteria or Staphylococcus aureus, most commonly identified in a true folliculitis. 3, 15 In addition to true folliculitis, the differential for PFB includes traumatic folliculitis, aka “razor burn,” a form of irritation contact dermatitis secondary to shaving which usually lasts for a day or two. Acne can also be considered but typically contains comedones and is much more common on the non-hair-bearing areas of the face. Other considerations are flat warts, and molluscum contagiosum the latter, characterized by flesh-colored, umbilicated papules. Both warts and molluscum can spread via shaving.
Hyperpigmentation and thickening of the skin admixed with pseudofolliculitis barbae (PFB).
The Army and Navy have separate but related guidelines on the management of PFB. The Army’s TBMED, is the most detailed of these and triages treatments based on three grades of severity. 17 The Navy’s most recent BUPERS Instruction 1000.22C, published in 2019, simplifies treatments into two separate approaches: one for mild-to-moderate PFB, and the other for moderate to-severe PFB. 13 Air Force instructions delegate PFB treatment and management strategies to the regulations of the individual MTFs. 18 This allows for decentralized control of PFB policy but result in differing policies from one MTF to another. The Marine Corps instruction divides treatment into four graduated phases. Progression through the phases is based on severity and responsiveness to treatment. 19 Table S1 provides a more detailed overview of the Uniformed Services Policies.
Treatment options for PFB are relatively well documented in the literature and vary based on disease severity. 20 Specific grooming techniques, topical treatments, limitations on shaving, and laser treatments are common themes shared in the Army, Navy, and Marine Corps guidelines. There is, however, variation on specific treatment recommendations by individual Service and sometimes even contradiction. For example, the use of topical eflornithine is a part of Navy’s PFB treatment guidelines, but its use is specifically not recommended by the Marine Corps. We offer a more uniformed approach to treating PFB in the military and provide evidence when available. Different treatment modalities are discussed first, followed by an approach to using the different treatment options.
All patients with PFB should be educated on specific grooming techniques to prevent cutting the hair too short and subsequent formation of a sharp hair tip. Before shaving, a hot wet washcloth should be applied to the beard for five minutes, followed by application of a lubricating shave gel before shaving. A 1979 study using a dermabrasion pad (Buf-Puf) in a similar fashion demonstrated a 96% success rate with satisfactory improvement at about 6 weeks. 9 Shaving should be done superior to inferior in a single pass without stretching the skin or applying firm pressure. Furthermore, the razor must be kept sharp by frequent replacement. Single-bladed razor with a foil guard (Bump Fighter) prevents cutting the hairs too short. Alternatives include multiblade razor with lubricating strips, or an electric razor. 4, 6 Multiblade razors can cause the hair to be pulled upward out of the follicle before being cut which can lead to the retraction of hair beneath the surface of the skin and contribute to the development of PFB. However, the effects of multiblade razors may be abated with a proper pre-shave hydration and post-shave moisturization. 6 Post-shave moisturizers should be utilized to decrease irritation of the skin after shaving. For patients who suffer from further irritation, topical hydrocortisone 1% can be utilized. Some patients may find these grooming guidelines easier to perform before bedtime.
Depilatories are another method to remove hairs. They soften the hair tip by breaking disulfide bonds but are not utilized much because of the amount of time required for its use, skin irritation, and foul odor. 4
Both topical tretinoin and combination of benzoyl peroxide/clindamycin have been shown to be effective treatments for PFB. 16, 21 Topical tretinoin works by reducing thickening of the skin and making the skin more resilient. It is available as 0.025%, 0.05% and 0.1% cream or gel. Tretinoin 0.025% cream is the least irritating of these and can be utilized as first-line treatment; patients may work up to a higher strength tretinoin as tolerated. Adapalene 0.1% cream may be better tolerated than tretinoin among patients with sensitive skin. A “pea-sized” amount of a retinoid can be applied and spread to cover the beard and neck at nighttime and washed off in the morning. Benzoyl peroxide 5%/clindamycin 1% gel has keratolytic and antibacterial properties and can be used as an alternative or in combination with topical retinoids. It is applied twice a day to the PFB prone areas.
The biggest side effect from topical treatments is irritation. Patients with irritation may find it helpful to use topical medications less frequently and add moisturizers after treatment. Once the skin tolerates the topical medication better, it can be used as intended. Shaving less frequently may also help curb the irritation. It can take 4 to 6 weeks to see the full effects of the topical therapies. Although these treatments may help with mild and some moderate cases of PFB, more severe cases of PFB may not respond to even a combination of topical tretinoin and benzoyl peroxide/clindamycin.
If pustules or crusting is present, patients should be treated for a secondary bacterial infection with either topical or oral antibiotics, such as topical clindamycin solution 1% twice a day for 7 days, or if more severe, oral doxycycline 100 mg twice a day for 7 days.
Topical eflornithine 13.9% cream, which inhibits hair growth leading to thinner, weaker hairs, has been shown to hasten the resolution of PFB when used in conjunction with laser therapy. 22 Although its use as monotherapy seems promising, more work needs to be done to assess its efficacy.
The issuance of a shaving profile is highly effective in eliminating PFB. Instead of shaving, facial hair is clipped to a length of no more than 1/4 inch maximum. Hair growth to 1/8 inch is usually enough to resolve PFB in most cases. As the hair grows out, a toothpick or toothbrush can also be used in a circular motion to help dislodge the hairs. If PFB is mild enough, cessation of shaving may not be necessary but, in more severe cases, shaving should be stopped for a period of 60 days to allow for PFB to resolve and make afflicted skin more amenable to topical therapy. At the end of the profile, the service member should resume shaving again and be reassessed. Shaving limitation practices vary considerably by individual Service. The Navy has discontinued permanent shaving waivers, but temporary waivers may be utilized. The Army does allow a permanent waiver, but even these are reviewed on a yearly basis. The Air Force recently issued a memorandum allowing for five-year shaving waivers, from one-year previously, following feedback from Airmen. 22 A permanent “no-shave” waiver is not usually endorsed in the Marine Corps. In cases where the service member is not separated from service, Commanders can request for one through the Manpower and Reserve Affairs.
Laser therapy has supplanted other physical modalities as the gold standard of PFB treatment. It is effective in treating even the most severe cases of PFB. For best results, laser treatments must be tailored to skin and hair color. The neodymium:yttrium aluminum garnet (Nd:YAG) long-pulse laser with a wavelength of 1,064 nm is the best treatment for the majority with PFB—those with darker skin and hair. 23 It is available at dermatology clinics in MTFs. The alexandrite laser, with a wavelength of 755 nm, is more effective for lighter skin and hair. It is not desirable for darker skin types as it can cause a burn to surrounding skin and effects may be more short-lived than Nd:YAG. 23 Common and transient side effects of laser therapy include pain, erythema, and swelling of the skin perifollicularly (Fig. 2). Complications of therapy can include blistering, subsequent scar formation, and secondary infection (Fig. 3). There is a higher chance of complications in patients with darker (Fitzpatrick skin type VI in particular) skin; however, even with blistering, patients often heal without permanent sequela. Patients usually require between four to six treatments, spaced about four to six weeks apart from each session. The hair becomes thinner and grows slower but permanent hair removal is seldom achieved. Consequently, following the initial treatment series, patients can opt to have maintenance treatments several times a year or wait until their hair regrows and PFB becomes an issue again. This may take anywhere from a year to several years.
Transient perifollicular edema is not uncommon post–laser treatment.
