STUDY Treatment of Pseudofolliculitis With a Pulsed Infrared Laser Arielle N. B. Kauvar, MD Background: Pseudofolliculitis barbae is a common dis- went evaluation for improvement in the pseudofollicu- order in individuals with thick, curly hairs, and treat- litis and the degree of hair reduction. ment options are limited. Main Outcome Measures: Patients were assessed at Objective: To evaluate the effectiveness of a diode la- 6- to 8-week intervals for the degree of hair-count re- ser in the treatment of pseudofolliculitis barbae. duction, improvements in papule and pustule forma- tion, and adverse effects. Design: Observational study. Results: Complete hair-growth delays of 3 to 8 weeks’ Setting: Laser and Skin Surgery Center of New York, duration were produced, and a decrease in hair density of New York, NY. greater than 50% was noted in all subjects 6 to 8 weeks after the last laser treatment. All patients exhibited greater Patients: Ten consecutive patients with long- than 50% improvement in the signs of pseudofolliculitis. standing pseudofolliculitis barbae and skin phototypes Preexisting pigmentary changes improved with therapy. ItoIV. Conclusion: Diode laser treatment is a safe and effec- Interventions: Treatment was performed using an tive method for improving pseudofolliculitis barbae in 810-nm diode laser (20- to 30-millisecond pulse dura- patients with skin phototypes I to IV. tion) at fluences of 30 to 40 J/cm2. Three treatments were performed at 6- to 8-week intervals, and subjects under- Arch Dermatol. 2000;136:1343-1346 SEUDOFOLLICULITIS BARBAE is a shaft. In both cases, a foreign body inflam- relatively common disorder matory reaction ensues. The primary le- that occurs in glabrous skin sions of pseudofolliculitis are erythema- with coarse, curly hairs.1-4 It is tous papules and pustules. When chronic a frequent disorder of any hair- inflammation is present, hyperpigmenta- Pbearing skin with thick, curly hairs that are tion, hypopigmentation, and fibrotic scar- removed repetitively by shaving, waxing, or ring may accompany the clinical picture. Bi- plucking. Prevalence figures are only avail- opsy results show foreign body giant cells able for pseudofolliculitis barbae occur- in the dermis with microabscess forma- ring in the beard area of African Ameri- tion.5 Cultures of the pustules are sterile, and cans who shave, and range from 45% to bacteria are therefore not implicated in the 83%.1 Shaving is a predisposing factor be- pathogenesis of this disorder.6 cause it results in a sharp, pointed, short hair Treatment modalities used for pseu- that may curl over and reenter the skin. Ex- dofolliculitis barbae have been largely dis- trafollicular penetration of the hair shaft is appointing, and include topical tretinoin one cause of pseudofolliculitis barbae. cream, corticosteroids, topical and oral an- Transfollicular penetration of the hair shaft tibiotics, surgical depilation, electrolysis, and may occur as well. When the skin is held tedious shaving regimens.2,7,8 Pseudofol- taut during shaving or when a double- liculitis barbae will improve if the hairs are edged razor is used, the sharply cut hair may allowed to grow. When shaving is stopped, retract under the skin and grow directly into the ingrown hairs are released automati- From the Laser and Skin the follicular wall. Incomplete wax epila- cally by spring action within a 3- to 4-week Surgery Center of New York, tion and electrolysis can also lead to trans- period. The only definitive cure for pseu- New York, NY. follicular penetration of the growing hair dofolliculitis barbae is permanent removal (REPRINTED) ARCH DERMATOL / VOL 136, NOV 2000 WWW.ARCHDERMATOL.COM 1343 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Patient Characteristics PATIENTS AND METHODS Patient No./ PATIENTS Age, y Skin Phototype Hair Color Location 1/18 III Black Bikini Ten consecutive patients seeking laser hair removal 2/31 III Black Axilla for the treatment of pseudofolliculitis barbae were en- 3/20 II Black Beard rolled in this study. The age of the patients ranged 4/35 IV Black Neck from 18 to 45 years. All patients had skin photo- 5/44 II Light brown Lip, chin types II to IV, with coarse curly hair ranging in color 6/22 II Brown Buttock from brown to black (Table). Each patient had a his- 7/45 II Black Lip, chin tory of pseudofolliculitis barbae in the treatment area 8/43 II Black Beard for a minimum duration of 1 year; patients 1 and 4 9/40 II Brown Bikini 10/28 II Black Bikini also had long-standing hyperpigmentation. Previ- ous treatments included topical antibiotics, oral an- tibiotics, and intralesional corticosteroid injections. damage or destruction has been demonstrated with a va- TREATMENT riety of laser systems, including ruby lasers,9,10 diode la- sers,11 alexandrite lasers,12 Nd:YAG lasers,13,14 and a pulsed After informed consent was obtained, 35-mm pho- 15 tographs were taken of the treatment area. The area noncoherent light source. Although all of these systems was shaved with a disposable razor, and a eutectic have been shown to be effective in delaying hair re- mixture of local anesthetics (lidocaine hydrochlo- growth, recent studies have demonstrated that some pulsed ride and prilocaine hydrochloride in an emulsion base) laser and light-source hair-removal systems are capable of was applied with occlusion for 1 hour before treat- producing a permanent reduction in hair density in the ment. An 810-nm diode laser (Lighsheer; Coherent treated areas. Star, Palo Alto, Calif) was used with a 9-mm spot size The successful treatment of pseudofolliculitis bar- and a pulse width of 20 milliseconds. Treatment flu- bae in 10 women is reported herein. ences ranged from 30 to 38 J/cm2. The affected areas were treated with contiguous laser pulses, and care was taken to stretch the skin during treatment to en- RESULTS sure close contact between the sapphire cooled hand- piece and the patient’s skin. After treatment, a hy- All patients tolerated the laser treatments well and expe- drogel dressing was placed, and patients were rienced minimal discomfort. Perifollicular edema and ery- instructed to apply a combination of bacitracin zinc thema developed immediately after laser treatment and and polymixin B sulfate (Polysporin) or bacitracin lasted 2 to 3 days. Blister formation did not occur in any ointment twice daily if crusting was present. The 2 of the treatment areas. Two patients reported scattered crusts patients with hyperpigmentation were treated with after the first treatment that resolved in 2 to 3 days. Com- 4% hydroquinone cream (Lustra; Medicis, Phoenix, plete hair-growth delays of 3 to 4 weeks’ duration were re- Ariz), which they began applying 1 week after each ported for facial hair, and 4 to 6 weeks for inguinal and ax- treatment. Follow-up visits and additional treatments were illary sites. In other body sites, patients reported complete performed at 6- to 8-week intervals. Patients were in- growth delays of 4 to 6 weeks. At the last follow-up visit, a structed to shave the treatment area as needed be- decrease in hair density of greater than 50% was observed tween treatment sessions. During each visit, 35-mm in all patients. After 3 treatments, all patients reported greater photographs were obtained, and an additional treat- than 75% improvement in the papules and pustule forma- ment was performed as before. Each patient under- tion (Figure 1). Patients 1 and 4 had a history of firm hy- went 3 laser treatments. Grading was performed by perpigmented papules and nodules measuring up to 5 mm 2 independent investigators comparing pretreat- in diameter that were present for longer than 3 and 5 years, ment and posttreatment photographs. Hair counts respectively (Figure 2). Both patients underwent elec- were determined from 35-mm photographs ob- trolysis treatments in the past, which were discontinued tained before shaving the treatment area. A quartile grading system was used to rate papule and pustule after the development of pseudofolliculitis barbae in the formation, pigmentary changes, and hair density re- affected areas. Patient 1 demonstrated an improvement rat- ductions as follows: 1 indicated 0% to 25% improve- ing of 4 and patient 4 showed an improvement rating of 3 ment; 2, 26% to 50%; 3, 51% to 75%; and 4, greater in hyperpigmentation. The degree of hair reduction at the than 75%. Patients were also questioned regarding last follow-up visit was rated at least 3 in all patients their satisfaction with the treatment and their im- (Figure 3). All patients were uniformly satisfied with their pressions were recorded. treatment and noted improvement after just 1 treatment session. COMMENT of the hair follicles. Surgical depilation carries a high mor- bidity. Electrolysis is a laborious procedure, and incom- Pseudofolliculitis barbae is a common disorder of gla- plete follicular destruction has resulted in keratin granu- brous skin in individuals with course, curly hair that de- lomas and pseudofolliculitis barbae. Selective follicular velops following hair removal, most commonly by shav- (REPRINTED) ARCH DERMATOL / VOL 136, NOV 2000 WWW.ARCHDERMATOL.COM 1344 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 10 A Hair Reduction Pseudofolliculitis Improvement 8 6 4 No. of Patients 2 0 123 4 Improvement Rating Figure 1. Improvement in pseudofolliculitis and degree of hair reduction in B 10 patients after 3 treatments: 1 indicates 0% to 25% improvement; 2, 26% to 50%; 3, 51% to 75%; and 4, greater than 75%. A Figure 3. Pseudofolliculitis of the chin and submental skin before (A) and 2 months after (B) treatment with the diode laser. B be achieved.16 Several other laser systems have been de- veloped with the same goal in mind, and include the di- ode laser (800-810 nm), pulsed alexandrite laser (755 nm), Nd:YAG laser (1064 nm), and a pulsed noncoherent light source.