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Barber Knowledge and Recommendations Figure. Comparison of Barber Recommendations Regarding Home Care Regarding Pseudofolliculitis Barbae for Clients With Pseudofolliculitis Barbae (PFB) and Keloidalis Nuchae in an Urban Setting and (AKN) Pseudofolliculitis barbae (PFB) and acne keloidalis nuchae 30 (AKN) are chronic inflammatory conditions affecting fol- Skin diagnosis licles common in men of color who are genetically inclined to AKN 1 25 have tightly curled hair. The incidence of PFB and AKN PFB among African American men may be as high as 83.0% and 20 13.6%, respectively.2,3 The barbershop represents a distinctly important institu- 15 tion in the African American community and constitutes a cul-

turally appropriate venue for barbers to provide men with Barbers, No. 10 health information.4

The knowledge and expertise afforded by barbers regard- 5 ing dermatologic evaluation and intervention of common scalp

and hair problems in this population has not been evaluated. 0 The aim of this cross-sectional study was to assess barber per- Use Chemical Do Not Shave Using Shave Using Depilatories Shave Clippers Razors ceptions and recommendations regarding PFB and AKN in pre- Barber Recommendations Regarding Home Care dominantly African American barbershops.

Methods | This cross-sectional study was approved by the in- knew that razor use would worsen AKN, their ideas on how to stitutional review board at the University of Oklahoma Health address these conditions differed widely (Figure). Avoiding Sciences Center, Oklahoma City. We collected a list of barber- shaving completely is a valid consideration and arguably the shops in the greater Oklahoma City area servicing predomi- most effective way to treat both conditions; however, this ap- nantly African American clientele. No more than 2 barbers were proach severely limits styling and grooming practice options selected at each shop. Each barber provided verbal consent and for a client. Dermatologists have an opportunity to educate bar- participated in a 20-question survey. Each barber was then bers about various treatment options available, such as chemi- given an educational pamphlet on PFB and AKN. The pam- cal depilatories, clippers use, or referral to a dermatologist for phlet showed digital images of these skin conditions and ex- topical or oral prescription or hair removal. plained how to manage them or when to refer to a dermatolo- A 2014 review of barber-administered health education gist. All the data was collected using REDCAP (Research programs in African American communities showed that edu- Electronic Data Capture). cational training promotes positive health behaviors among customers.4 Barbers represent a unique resource to commu- Results | Fifty barbers from 37 barbershops in greater Okla- nicate medical information to clients. This opens a potential homa City were enrolled from April through May, 2017. Of collaborative opportunity among barbers, clients, and health these, 39 barbers (78%) properly identified PFB while only 22 care professionals. (44%) were able to identify AKN from a photograph. Eight bar- Limitations of this study include recall bias and general- bers (16%) confused PFB with , a fungal izability because of data collection in a single city. limited to the bearded region, and 15 (30%) confused AKN with Barbers can identify PFB and, in fewer clients, AKN, and tinea barbae. often advise them how to care for these medical conditions. Twenty-nine barbers (58%) indicated that they avoid cut- The dermatologic community can offer appropriate guidance ting the hair of clients who have PFB and 23 (46%) avoid cut- so that barbers can become a unique ally in recognizing and ting hair of clients who have AKN. Among the respondents, 47 treating PFB and AKN. (94%) knew that razor use would aggravate AKN and 49 (98%) knew it would aggravate PFB. Nineteen barbers (38%) ad- Prince Adotama, MD vised clients with PFB and 26 (52%) counseled clients with AKN Daniel Tinker, BS to never shave at home. Twenty-two barbers (44%) coun- Krystal Mitchell, MBA seled clients to shave with clippers at home for PFB and 14 Donald A. Glass II, MD, PhD (28%) for AKN (Figure). Recommendation to use chemical de- Pamela Allen, MD pilatories was not favored. Author Affiliations: Department of , University of Oklahoma Discussion | The majority of the barbers identified PFB. It was Health Science Center, Oklahoma City (Adotama, Allen); Medical student, more difficult to identify AKN, with only 44% of participants University of Oklahoma College of Medicine, Oklahoma City (Tinker, Mitchell); Department of Dermatology, University of Texas Southwestern Medical Center, recognizing this condition. Tinea barbae was a competing di- Dallas (Glass). agnosis for PFB (16%) and, more commonly, for AKN (30%). Corresponding Author: Pamela Allen, MD, Department of Dermatology, This suggests that more education for barbers regarding diag- University of Oklahoma Health Science Center, 619 NE 13th St, Oklahoma City, nosis and treatment of fungal is necessary. While OK 73104 ([email protected]). 94% of barbers knew that razor use would worsen PFB and 98% Accepted for Publication: July 30, 2017.

jamadermatology.com (Reprinted) JAMA Dermatology December 2017 Volume 153, Number 12 1325

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Published Online: October 18, 2017. doi:10.1001/jamadermatol.2017.3668 infection involves the matrix, systemic therapy is often Author Contributions: Dr Adotama and Mr Tinker had full access to all of the indicated.2 is the systemic of choice, data in the study and take responsibility for the integrity of the data and the with cure rates as high as 80%.3 Though terbinafine is well tol- accuracy of the data analysis. erated, hepatotoxic effects have been reported in adults.4 There Study concept and design: Adotama, Glass, Allen. Acquisition, analysis, or interpretation of data: Adotama, Tinker, Mitchell. are fewer risk factors for liver in children and consen- Drafting of the manuscript: Adotama, Tinker, Mitchell. sus regarding laboratory surveillance during therapy has not Critical revision of the manuscript for important intellectual content: All authors. been reached, with preference varying widely. The Statistical analysis: Adotama, Tinker, Mitchell. Administrative, technical, or material support: Adotama, Tinker, Mitchell. aim of our study was to investigate the prevalence of labora- Study supervision: Adotama, Tinker, Allen. tory monitoring and laboratory abnormalities during sys- Conflict of Interest Disclosures: None reported. temic terbinafine therapy in pediatric patients with onycho- 1. Alexis A, Heath CR, Halder RM. keloidalis nuchae and . pseudofolliculitis barbae: are prevention and effective treatment within reach? Dermatol Clin. 2014;32(2):183-191. Methods | We conducted an institutional review board- 2. Perry PK, Cook-Bolden FE, Rahman Z, Jones E, Taylor SC. Defining approved retrospective medical record review of patients seen pseudofolliculitis barbae in 2001: a review of the literature and current trends. J Am Acad Dermatol. 2002;46(2)(Suppl Understanding):S113-S119. at Children’s Hospital of Philadelphia for from 3. Olsen EA, Bergfeld WF, Cotsarelis G, et al; Workshop on Cicatricial Alopecia. December 2008 to December 2016. Patients not prescribed sys- Summary of North American Hair Research Society (NAHRS)–sponsored temic terbinafine therapy were excluded. Laboratory abnor- workshop on cicatricial alopecia, Duke University Medical Center, February 10 malities were graded based on The National Cancer Institute and 11, 2001. J Am Acad Dermatol. 2003;48(1):103-110. Common Terminology Criteria for Adverse Events (version 4. Luque JS, Ross L, Gwede CK. Qualitative of 4.03).5 Statistical analyses were performed using Stata statis- barber-administered health education, promotion, screening and outreach programs in African-American communities. J Community Health. 2014;39(1): tical software (version 14.2, Stata Corp). 181-190. Results | Over an 8-year period, 1302 patients were diagnosed Laboratory Monitoring During Systemic Terbinafine with onychomycosis. Of these, 269 (21%) were prescribed oral Therapy for Pediatric Onychomycosis terbinafine and were included in analysis (Table 1 and Table 2). Onychomycosis is a fungal infection of the nail resulting in dis- A total of 192 (71.4%) patients were treated by pediatricians and coloration, thickening, and separation from the nail bed. Pe- 77 (28.6%) were treated by pediatric dermatologists. Mean (SD) diatric onychomycosis has a reported incidence of 0.4% to age at initial presentation was 11.5 (3.9) years (range, 2-20 years). 2.6%.1 Topical antifungal therapy has been shown to have some The male to female ratio of the study population was 1.5:1.0, in children compared with adults; however, when the with 160 (59%) male patients and 109 (41%) female. Diagnosis of onychomycosis was confirmed by nail cul- ture and/or periodic–acid schiff (PAS) stain in 128 (48%) cases Table 1. Demographics of the Study Population and Patients Who Underwent Laboratory Monitoring prior to initiation of treatment. Seventy-two (56%) patients had positive culture results, 44 (34%) patients had positive PAS stain Overall Demographics of Study Population Finding results, and 12 (9%) patients had both. Patients prescribed terbinafine, No. 269 Mean (SD) number of treatment courses was 1.1 (0.3) and Age, mean (SD), y 11.5 (3.9) mean (SD) duration was 11.8 (2.3) weeks. Mean (SD) time to , No. (%) complete resolution was 5.0 (1.9) months. Cure rates were all Female 109 (41) determined clinically. A total of 144 (53.5%) patients under- Male 160 (59) went laboratory monitoring of liver function panels and/or Nail involved, No. (%) complete blood cell counts. Timing of laboratory monitoring Toenail(s) 263 (98) was primarily prior to treatment (34 patients, 23.6%) or prior Fingernail(s) 1 (<1) to treatment and at 6 weeks (102 patients, 70.8%). Whereas Unknown 5 (2) 126 (87.5%) patients had normal laboratory results, 18 (12.5%) Prescribed daily oral terbinafine dose,a No. (%) patients had grade 1 laboratory abnormalities either prior to 62.5 mg (<20 kg) 1 (<1) (12 patients, 8.3%) or during therapy (6 patients, 4.2%). In those 125 mg (20-40 kg) 93 (35) with abnormal results during therapy, 3 patients discontin- 250 mg (>40 kg) 174 (65) ued treatment. Only 1 patient reported an adverse effect (ur- Other (187.5 mg per dosing) 1 (<1) ticaria) at 3 weeks and treatment was stopped. Patients with treatment extended beyond typical course 6 (2) duration,b No. (%) Discussion | The US Food and Drug Administration (FDA) label- Toenail(s) 5 ing for systemic terbinafine specifically states that the safety Fingernail(s) 1 and efficacy in pediatric patients has not been established but a Weight-based dosing used based on prior studies and clinical practice in adults recommends pretreatment serum transaminases although no standard dosing guidelines in pediatric patients per drug insert.4 and laboratory monitoring periodically during therapy.4 Of b Duration of therapy based on adult guidelines of 6 weeks of total therapy for the 144 patients prescribed systemic terbinafine who under- fingernail onychomycosis and 12 weeks of total therapy for toenail went laboratory monitoring, none developed more than a onychomycosis.4 grade 1 laboratory abnormality. In otherwise healthy children,

1326 JAMA Dermatology December 2017 Volume 153, Number 12 (Reprinted) jamadermatology.com

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