Skin of Color Savvy: Razor Bumps—Treating Pseudofolliculitis Barbae in Skin of Color

Welcome to Skin of Color Savvy: The Art and Science of Treating Patients of Color!

In this October episode of the Skin of Color Savvy podcast, guest host Prince Adotama, MD, of NYU Grossman School of Medicine, spoke with Yoseph Dalia, MD, a dual board-certified dermatologist and dermatopathologist affiliated with Johns Hopkins Medicine and a committee member of the Skin of Color Society (SOCS), about diagnosing and managing pseudofolliculitis barbae (PFB), commonly known as razor bumps.

During this conversation, Dalia explained PFB is a chronic inflammatory condition that develops when a hair fails to exit the skin, called a transfollicular pathway, or exits and curls back into it, called an extrafollicular pathway. In both cases, the body mounts a foreign body reaction against the hair shaft.

While PFB can affect anyone who shaves, Dalia said it occurs more often and more severely in people with tightly coiled hair, particularly those of African descent, since that hair type tends to grow more parallel to the skin surface and is more likely to reenter it. He noted a possible genetic contributor involving the keratin 6 hf protein, though research remains limited.

What Does PFB Mean for Patients Who Must Shave for Work?

Adotama asked how PFB affects people required to shave for occupational reasons, including military service members, firefighters, and health care workers who need a proper respirator fit. Dalia said stigma around shave waivers persists even where policies exist, and research has linked PFB to reduced promotion opportunities for affected service members. He recommended clinicians keep shave waiver forms pre-printed and use indefinite timelines, given the condition’s chronic nature, and said public education for employers and patients about the risk of permanent scarring and pigment change is essential.

How Is PFB Diagnosed and Differentiated From Other Conditions?

Dalia said diagnosis relies on a history of recurrent, follicular-based bumps that worsen after shaving, often in the beard area, supported by dermoscopy to confirm hairs reentering the skin. PFB lesions tend to form thicker, deeper nodules compared with the more superficial pustules typical of bacterial or fungal folliculitis. Signs of chronicity, including scarring and post-inflammatory hyperpigmentation, further support the diagnosis. Dalia distinguished PFB from folliculitis decalvans and dissecting cellulitis, which typically present on the scalp, and from acne keloidalis nuchae, which occurs at the nape of the neck rather than the beard area.

What Treatment Options Are Available for PFB?

Dalia said treatment begins by establishing whether a patient wants to stop shaving or keep facial hair. Behavioral changes such as shaving cessation or switching to an electric trimmer can help, alongside options like chemical depilatories, tested first on an inconspicuous area, laser hair removal, or electrolysis. Medical management may include topical retinoids and salicylic acid for keratinization, benzoyl peroxide and clindamycin for inflammation, and low-potency topical steroids. Acute flares may warrant oral doxycycline or intralesional steroids, while chronic scarring and pigmentation changes are managed separately with lightening agents or laser therapy. Dalia said a stepwise approach, rather than introducing every treatment at once, improves adherence.

Dalia and Adotama also addressed common misconceptions, noting PFB is not caused by poor hygiene and is not contagious, and that picking or plucking affected areas can worsen the condition. Both emphasized educating barbers and hairstylists, who often have more frequent contact with patients than dermatologists do.¹ They closed by calling for expanded insurance coverage of laser hair removal, noting only a small share of states currently require it, along with continued research and individual patient advocacy.²

To learn more about SOCS’s programs and initiatives, visit the Skin of Color Society website.

Editor's note: Both Adotama and Dalia had no relevant disclosures of note. This episode summary was edited with the help of AI tools.

References

1. Rice X, Omar D, Goodwin BP, Adotama P. Barber knowledge and recommendations for pseudofolliculitis barbae. JAMA Dermatol. 2024;160(1):111-113. doi:10.1001/jamadermatol.2023.4913.

2. Ahuja R, Olagun-Samuel C, Rodriguez E, Vasquez R, Adotama P. State-based insurance coverage access to laser hair reduction for the treatment of pseudofolliculitis barbae: an evaluation of public and private policies. J Am Acad Dermatol. 2025;93(2):542-543. doi:10.1016/j.jaad.2025.04.024.