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Quiz

Irritable rash in the beard area

Figures

Fig 1. Irritable rash
Figure 1. Irritated follicular papules on the cheek and neck.
Fig 2. Buried hairs
Figure 2. Detail of the skin demonstrating a series of buried hairs as well as scarred areas lacking follicles.
STEVEN KOSSARD, FACD

A 37-year-old man developed an irritable papular eruption over his beard area and extending down his neck (Figure 1). Over a period of two years, shaving had become difficult. Individual lesions were eroded and there were scattered follicular pustules. The beard area appeared highly irritated. Close examination showed that many of the hairs were buried under the skin surface (Figure 2) and there was a background of erythema with scarring.

Differential diagnosis

The differential diagnosis for follicular pustules on the cheeks and neck includes the following.
  • Acne is characterised by the presence of comedones as well as follicular pustules, and usually has a more extensive facial distribution and an earlier age of onset.

  • Rosacea may be associated with follicular pustules but there is a background of flushing and erythema which may lead to facial oedema. The follicular pustules in rosacea are usually localised to the cheeks while the neck is relatively spared.

  • Gram-negative folliculitis is characterised by follicular pustules and is usually localised to the perioral area and chin. It occurs in the setting of acne treated with long term tetracyclines. Cultures may reveal a variety of Gram-negative organisms.

  • Pseudofolliculitis barbae is the correct diagnosis. This condition is seen particularly in individuals with black, curly hair. Close shaving or plucking hairs results in the hair snapping back and perforating the hair canal. The buried hairs result in a foreign body reaction and, hence, a pseudofolliculitis. However, secondary bacterial infection may develop on the eroded skin. A similar process may be seen in women who shave or wax the lower limbs or pubic area.
    Management includes the cessation of shaving, which will encourage some of the hairs to emerge to the surface, and subsequently avoiding ‘clean’ shaving close to the skin surface. Embedded hairs at the surface should be extracted. Topical antibiotics – such as 1% clindamycin lotion – and topical retinoids can be helpful. Glycolic acid lotions may also be used to soften the hair prior to shaving.

Keypoint

Pseudofolliculitis barbae should be suspected in individuals who have irritable follicular lesions in the beard area and neck that fail to respond to antibiotics alone.

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