Case Report Access this article online Website: www.ijtrichology.com DOI:
Pseudofolliculitis Corporis: A New Entity Diagnosed by Dermoscopy Manas Ranjan Puhan, Bharati Sahu Department of Skin and VD, SCBMCH, Cuttack, Odisha, India
10.4103/0974-7753.153453 Quick Response Code:
Address for correspondence: Dr. Manas Ranjan Puhan, Niki Skin Care, Anadi Bhaban, Ranihat, Cuttack ‑ 753 001, Odisha, India. E‑mail: drpuhan123@yahoo. com
ABSTRACT Pseudofolliculitis mainly affects the beard area, but it can occur in any area of hair‑bearing skin when traumatic methods like shaving or plucking are used to remove the hair. It can be a simple cosmetic problem or a disturbing medical condition for which the dermatologist must be prepared. It can develop in areas of shaving or depilation and has been seen in the pubic region or the axilla, where it is common to find curly hair that emerges at an acute angle. Here, we are reporting a case of pseudofolliculitis over back, termed as pseudofolliculitis corporis. He used to put a pillow behind the back while driving and the pressure caused the pseudofolliculitis. The diagnosis was confirmed by dermoscopy, which is a simple office procedure. Patient was advised to stop using the pillow and improved with topical adapalene and clindamycin gel for 15 days. This entity has not been described in the literature.
Key words: Dermoscopy, ingrowing hair, pseudofolliculitis corporis
INTRODUCTION
P
seudofolliculitis is an inflammatory disorder that occurs most frequently in men with a dense and curly beard. Pseudofolliculitis barbae occurs when emerged terminal hairs, particularly the thick, curly hairs of the beard, grow back towards the surface.[1,2] It can be a simple cosmetic problem or a disturbing medical condition for which the dermatologist must be prepared. The submandibular area is most frequently affected due to the higher hair density and the oblique direction of hair growth in this area. Pseudofolliculitis is not confined to the beard area of the face. It can develop in areas of shaving or depilation and has been seen in the pubic region or the axillas, where it is common to find curly hair that emerges at an acute angle.[3] In individuals with very curly body hair, pseudofolliculitis can also occur after depilation of other areas such as the chest, back, or legs.[4] CASE REPORT
A 32‑year‑old male presented with mildly pruritic lesions over back since 3 years [Figure 1]. Previously he was diagnosed as truncal acne and treated with oral isotretinoin and multiple courses of antibiotics. There was partial improvement, but lesions were reappearing in few weeks. 30
He was a driver by occupation. On clinical examinations, there were follicular papules over mid portion of the back. On dermoscopy, the hairs were seen like loops [Figure 2a] and some of the lesions were solid papules [Figure 2b]. Few of the lesions were removed with a curette and examined on a piece of paper under dermoscope. Hairs coming out of the skin and again reentering in few lesions [Figure 3a] and the solid papules had bend hairs inside [Figure 3b]. The diagnosis of pseudofolliculitis corporis was made. On further questioning, he revealed that he used to put a pillow in the mid portion of his back while driving. He was explained of the fact that the lesions were due to the chronic friction and advised to stop that practice. He was advised adapalene and clindamycin combination gel for 15 days. On follow‑up at 6 months and 1‑year there was no recurrence. DISCUSSION
Pseudofolliculitis mainly affects the beard area, but it can occur in any area of hair‑bearing skin when traumatic methods like shaving or plucking are used to remove the hair.[5] The sharp ends of the hairs left by the oblique cut of the razor make contact with the epidermis at an angle of 90° and on penetration to the epidermis looks like a hair follicle, referred to as a pseudofollicle. A very close International Journal of Trichology / Jan-Mar 2015 / Vol-7 / Issue-1
Puhan and Sahu: Pseudofolliculitis corporis: A new entity diagnosed by dermoscopy
Figure 1: Pruritic follicular papules over back
a
b
Figure 2: (a) On dermoscopy the hairs were seen like loops. (b) Solid papules over back seen on dermoscopy
resolve spontaneously.[6] A recent study found a A12T polymorphism of the gene coding for keratin K6hf, found in a thin layer of cells between the inner and outer sheaths of the root of the hair follicle gives rise to a six‑fold increase in the risk of suffering pseudofolliculitis barbae.[7] Abnormalities in this keratin constitute a risk factor for pseudofolliculitis, and when thick wavy or curly hair is involved, hair ingrowth after shaving is more likely.[7,8] Another study has demonstrated that curly hair and the presence of whorls increase the risk of developing pseudofolliculitis barbae by more than 50%.[9] Pseudofolliculitis has been reported in the nose, caused by plucking the stiff nasal hairs or cutting them with scissors very close to the surface of the skin. The condition may also occur after preoperative shaving. Pseudofolliculitis can also be related to certain occupations in which the subject has to maintain a device or hard surface against the cheek for long periods of time. A classic case is “fiddler’s neck,” a form of pseudofolliculitis barbae caused by the pressure of the violin under the mandible.[10,11] Other causes of occupational pseudofolliculitis include the use of constricting objects, devices, or clothing that rub on hair‑bearing areas and produce depilation by friction. There have also been reports of cases related to the administration of medicines that can favor the acne, such as corticosteroids and ciclosporin.[12] The diagnosis of pseudofolliculitis barbae is based on clinical characteristics. Dermoscopy can be used to confirm the diagnosis.[13] In our case, we used dermoscopy for visualization of in growing hairs. Curetting the papule and putting the tissue over a white paper and again examining under dermoscope will give the diagnosis. As this is an office based procedure, can be done in any sitting and invasive procedures like biopsy can be avoided.
a
b
Figure 3: (a) Hairs coming out of the skin and again re‑entering. (b) Solid papules had bend hairs inside
shave may also cause the hair to pierce the epidermis before reaching the surface. Shaving against the grain while tensing the skin and on releasing the tension, the hair is drawn back below the skin surface may pierce the epidermis before reaching the surface leading to pseudofolliculitis. This phenomenon is less likely to occur with finer, less curved hairs or when the angle at which the hair is cut during shaving is perpendicular to the skin. If a person with pseudofolliculitis stops shaving, hair growth to a length of 10 mm usually pulls the hair out of the inflammatory papule, and the process tends to International Journal of Trichology / Jan-Mar 2015 / Vol-7 / Issue-1
The aim of treatment is to reduce extrafollicular and transfollicular hair penetration and to reduce chronic inflammation. Avoidance of the cause is most important as our case improved due to the simple advice (stopped using pillow behind back while driving). It is advisable to stop shaving for around 4 weeks and attempts can be made to remove the ingrown hairs by freeing them with a sterile needle. When these methods are insufficient, or the inflammation becomes severe, medical treatment is required.[14] The only published randomized clinical trial included 88 men who were treated with a gel containing 5% benzoyl peroxide plus 1% clindamycin or a placebo gel for 10 weeks.[15] Pseudofolliculitis corporis over back has not been described in the literature. Though driving with a pillow behind the 31
Puhan and Sahu: Pseudofolliculitis corporis: A new entity diagnosed by dermoscopy
back is very common, this entity is less recognized. High index of suspicion, simple investigations like dermoscopy will give the diagnosis. Once confirmed, avoidance of pressure factor and topical treatment will give cure to the patient. REFERENCES 1. 2. 3. 4. 5. 6. 7.
Tolgyesi E, Coble DW, Fang FS, Kairinen EO. A comparative study of beard and scalp hair. J Soc Cosmet Chem 1983;34:361‑2. Brown LA Jr. Pathogenesis and treatment of pseudofolliculitis barbae. Cutis 1983;32:373‑5. Ribera M, Fernández‑Chico N, Casals M. Pseudofolliculitis barbae. Actas Dermosifiliogr 2010;101:749‑57. Dilaimy M. Pseudofolliculitis barbae of the legs. Arch Dermatol 1974;112:507‑8. Dunn JF Jr. Pseudofolliculitis barbae. Am Fam Physician 1988;38:169‑74. Strauss JS, Klingman AM. Pseudofolliculitis of the beard. Arch Dermatol 1956;74:533‑42. Winter H, Schissel D, Parry DA, Smith TA, Liovic M, Birgitte Lane E, et al. An unusual Ala12Thr polymorphism in the 1A alpha‑helical segment of the companion layer‑specific keratin K6hf: Evidence for a risk factor in the etiology of the common hair disorder pseudofolliculitis barbae. J Invest
8. 9. 10. 11. 12. 13. 14. 15.
Dermatol 2004;122:652‑7. Winter H, Langbein L, Praetzel S, Jacobs M, Rogers MA, Leigh IM, et al. A novel human type II cytokeratin, K6hf, specifically expressed in the companion layer of the hair follicle. J Invest Dermatol 1998;111:955‑62. Ross EV, Evans LA, Yeager JK. Pseudofolliculitis barbae associated with an unusual hair whorl. Cutis 1993;51:107‑8. Lachapelle JM, Tennstedt D, Cromphaut P. Pseudofolliculitis of the beard and “fiddler’s neck”. Contact Dermatitis 1984;10:247. Fisher AA. Dermatitis in a musician. Part III: Injuries caused by specific musical instruments. Cutis 1998;62:261‑2. Lally A, Wojnarowska F. Hypertrophic pseudofolliculitis in white renal transplant recipients. Clin Exp Dermatol 2007;32:268‑71. Ladizinski B, Ramirez‑Fort MK, Cohen YK, Rosendahl C, Elpern DJ. Pseudofolliculitis barbae: A dermatoscopic correlate. Dermatol Pract Concept 2013;3:53‑4. Halder RM, Richards GM. Therapeutic approaches for pseudofolliculitis barbae. Cosmet Dermatol 2003;16:42‑5. Cook‑Bolden FE, Barba A, Halder R, Taylor S. Twice‑daily applications of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae. Cutis 2004;73:18‑24.
How to cite this article: Puhan MR, Sahu B. Pseudofolliculitis corporis: A new entity diagnosed by dermoscopy. Int J Trichol 2015;7:30-2. Source of Support: Nil, Conflict of Interest: None declared.
Author Help: Reference checking facility The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. • The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference. • Example of a correct style Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. Otolaryngol Head Neck Surg 2002;127:294-8. • Only the references from journals indexed in PubMed will be checked. • Enter each reference in new line, without a serial number. • Add up to a maximum of 15 references at a time. • If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct article in PubMed will be given. • If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to possible articles in PubMed will be given. 32
International Journal of Trichology / Jan-Mar 2015 / Vol-7 / Issue-1
Copyright of International Journal of Trichology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Pseudofolliculitis Corporis: A New Entity Diagnosed by Dermoscopy Manas Ranjan Puhan, Bharati Sahu Department of Skin and VD, SCBMCH, Cuttack, Odisha, India
10.4103/0974-7753.153453 Quick Response Code:
Address for correspondence: Dr. Manas Ranjan Puhan, Niki Skin Care, Anadi Bhaban, Ranihat, Cuttack ‑ 753 001, Odisha, India. E‑mail: drpuhan123@yahoo. com
ABSTRACT Pseudofolliculitis mainly affects the beard area, but it can occur in any area of hair‑bearing skin when traumatic methods like shaving or plucking are used to remove the hair. It can be a simple cosmetic problem or a disturbing medical condition for which the dermatologist must be prepared. It can develop in areas of shaving or depilation and has been seen in the pubic region or the axilla, where it is common to find curly hair that emerges at an acute angle. Here, we are reporting a case of pseudofolliculitis over back, termed as pseudofolliculitis corporis. He used to put a pillow behind the back while driving and the pressure caused the pseudofolliculitis. The diagnosis was confirmed by dermoscopy, which is a simple office procedure. Patient was advised to stop using the pillow and improved with topical adapalene and clindamycin gel for 15 days. This entity has not been described in the literature.
Key words: Dermoscopy, ingrowing hair, pseudofolliculitis corporis
INTRODUCTION
P
seudofolliculitis is an inflammatory disorder that occurs most frequently in men with a dense and curly beard. Pseudofolliculitis barbae occurs when emerged terminal hairs, particularly the thick, curly hairs of the beard, grow back towards the surface.[1,2] It can be a simple cosmetic problem or a disturbing medical condition for which the dermatologist must be prepared. The submandibular area is most frequently affected due to the higher hair density and the oblique direction of hair growth in this area. Pseudofolliculitis is not confined to the beard area of the face. It can develop in areas of shaving or depilation and has been seen in the pubic region or the axillas, where it is common to find curly hair that emerges at an acute angle.[3] In individuals with very curly body hair, pseudofolliculitis can also occur after depilation of other areas such as the chest, back, or legs.[4] CASE REPORT
A 32‑year‑old male presented with mildly pruritic lesions over back since 3 years [Figure 1]. Previously he was diagnosed as truncal acne and treated with oral isotretinoin and multiple courses of antibiotics. There was partial improvement, but lesions were reappearing in few weeks. 30
He was a driver by occupation. On clinical examinations, there were follicular papules over mid portion of the back. On dermoscopy, the hairs were seen like loops [Figure 2a] and some of the lesions were solid papules [Figure 2b]. Few of the lesions were removed with a curette and examined on a piece of paper under dermoscope. Hairs coming out of the skin and again reentering in few lesions [Figure 3a] and the solid papules had bend hairs inside [Figure 3b]. The diagnosis of pseudofolliculitis corporis was made. On further questioning, he revealed that he used to put a pillow in the mid portion of his back while driving. He was explained of the fact that the lesions were due to the chronic friction and advised to stop that practice. He was advised adapalene and clindamycin combination gel for 15 days. On follow‑up at 6 months and 1‑year there was no recurrence. DISCUSSION
Pseudofolliculitis mainly affects the beard area, but it can occur in any area of hair‑bearing skin when traumatic methods like shaving or plucking are used to remove the hair.[5] The sharp ends of the hairs left by the oblique cut of the razor make contact with the epidermis at an angle of 90° and on penetration to the epidermis looks like a hair follicle, referred to as a pseudofollicle. A very close International Journal of Trichology / Jan-Mar 2015 / Vol-7 / Issue-1
Puhan and Sahu: Pseudofolliculitis corporis: A new entity diagnosed by dermoscopy
Figure 1: Pruritic follicular papules over back
a
b
Figure 2: (a) On dermoscopy the hairs were seen like loops. (b) Solid papules over back seen on dermoscopy
resolve spontaneously.[6] A recent study found a A12T polymorphism of the gene coding for keratin K6hf, found in a thin layer of cells between the inner and outer sheaths of the root of the hair follicle gives rise to a six‑fold increase in the risk of suffering pseudofolliculitis barbae.[7] Abnormalities in this keratin constitute a risk factor for pseudofolliculitis, and when thick wavy or curly hair is involved, hair ingrowth after shaving is more likely.[7,8] Another study has demonstrated that curly hair and the presence of whorls increase the risk of developing pseudofolliculitis barbae by more than 50%.[9] Pseudofolliculitis has been reported in the nose, caused by plucking the stiff nasal hairs or cutting them with scissors very close to the surface of the skin. The condition may also occur after preoperative shaving. Pseudofolliculitis can also be related to certain occupations in which the subject has to maintain a device or hard surface against the cheek for long periods of time. A classic case is “fiddler’s neck,” a form of pseudofolliculitis barbae caused by the pressure of the violin under the mandible.[10,11] Other causes of occupational pseudofolliculitis include the use of constricting objects, devices, or clothing that rub on hair‑bearing areas and produce depilation by friction. There have also been reports of cases related to the administration of medicines that can favor the acne, such as corticosteroids and ciclosporin.[12] The diagnosis of pseudofolliculitis barbae is based on clinical characteristics. Dermoscopy can be used to confirm the diagnosis.[13] In our case, we used dermoscopy for visualization of in growing hairs. Curetting the papule and putting the tissue over a white paper and again examining under dermoscope will give the diagnosis. As this is an office based procedure, can be done in any sitting and invasive procedures like biopsy can be avoided.
a
b
Figure 3: (a) Hairs coming out of the skin and again re‑entering. (b) Solid papules had bend hairs inside
shave may also cause the hair to pierce the epidermis before reaching the surface. Shaving against the grain while tensing the skin and on releasing the tension, the hair is drawn back below the skin surface may pierce the epidermis before reaching the surface leading to pseudofolliculitis. This phenomenon is less likely to occur with finer, less curved hairs or when the angle at which the hair is cut during shaving is perpendicular to the skin. If a person with pseudofolliculitis stops shaving, hair growth to a length of 10 mm usually pulls the hair out of the inflammatory papule, and the process tends to International Journal of Trichology / Jan-Mar 2015 / Vol-7 / Issue-1
The aim of treatment is to reduce extrafollicular and transfollicular hair penetration and to reduce chronic inflammation. Avoidance of the cause is most important as our case improved due to the simple advice (stopped using pillow behind back while driving). It is advisable to stop shaving for around 4 weeks and attempts can be made to remove the ingrown hairs by freeing them with a sterile needle. When these methods are insufficient, or the inflammation becomes severe, medical treatment is required.[14] The only published randomized clinical trial included 88 men who were treated with a gel containing 5% benzoyl peroxide plus 1% clindamycin or a placebo gel for 10 weeks.[15] Pseudofolliculitis corporis over back has not been described in the literature. Though driving with a pillow behind the 31
Puhan and Sahu: Pseudofolliculitis corporis: A new entity diagnosed by dermoscopy
back is very common, this entity is less recognized. High index of suspicion, simple investigations like dermoscopy will give the diagnosis. Once confirmed, avoidance of pressure factor and topical treatment will give cure to the patient. REFERENCES 1. 2. 3. 4. 5. 6. 7.
Tolgyesi E, Coble DW, Fang FS, Kairinen EO. A comparative study of beard and scalp hair. J Soc Cosmet Chem 1983;34:361‑2. Brown LA Jr. Pathogenesis and treatment of pseudofolliculitis barbae. Cutis 1983;32:373‑5. Ribera M, Fernández‑Chico N, Casals M. Pseudofolliculitis barbae. Actas Dermosifiliogr 2010;101:749‑57. Dilaimy M. Pseudofolliculitis barbae of the legs. Arch Dermatol 1974;112:507‑8. Dunn JF Jr. Pseudofolliculitis barbae. Am Fam Physician 1988;38:169‑74. Strauss JS, Klingman AM. Pseudofolliculitis of the beard. Arch Dermatol 1956;74:533‑42. Winter H, Schissel D, Parry DA, Smith TA, Liovic M, Birgitte Lane E, et al. An unusual Ala12Thr polymorphism in the 1A alpha‑helical segment of the companion layer‑specific keratin K6hf: Evidence for a risk factor in the etiology of the common hair disorder pseudofolliculitis barbae. J Invest
8. 9. 10. 11. 12. 13. 14. 15.
Dermatol 2004;122:652‑7. Winter H, Langbein L, Praetzel S, Jacobs M, Rogers MA, Leigh IM, et al. A novel human type II cytokeratin, K6hf, specifically expressed in the companion layer of the hair follicle. J Invest Dermatol 1998;111:955‑62. Ross EV, Evans LA, Yeager JK. Pseudofolliculitis barbae associated with an unusual hair whorl. Cutis 1993;51:107‑8. Lachapelle JM, Tennstedt D, Cromphaut P. Pseudofolliculitis of the beard and “fiddler’s neck”. Contact Dermatitis 1984;10:247. Fisher AA. Dermatitis in a musician. Part III: Injuries caused by specific musical instruments. Cutis 1998;62:261‑2. Lally A, Wojnarowska F. Hypertrophic pseudofolliculitis in white renal transplant recipients. Clin Exp Dermatol 2007;32:268‑71. Ladizinski B, Ramirez‑Fort MK, Cohen YK, Rosendahl C, Elpern DJ. Pseudofolliculitis barbae: A dermatoscopic correlate. Dermatol Pract Concept 2013;3:53‑4. Halder RM, Richards GM. Therapeutic approaches for pseudofolliculitis barbae. Cosmet Dermatol 2003;16:42‑5. Cook‑Bolden FE, Barba A, Halder R, Taylor S. Twice‑daily applications of benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of pseudofolliculitis barbae. Cutis 2004;73:18‑24.
How to cite this article: Puhan MR, Sahu B. Pseudofolliculitis corporis: A new entity diagnosed by dermoscopy. Int J Trichol 2015;7:30-2. Source of Support: Nil, Conflict of Interest: None declared.
Author Help: Reference checking facility The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. • The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference. • Example of a correct style Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. Otolaryngol Head Neck Surg 2002;127:294-8. • Only the references from journals indexed in PubMed will be checked. • Enter each reference in new line, without a serial number. • Add up to a maximum of 15 references at a time. • If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct article in PubMed will be given. • If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to possible articles in PubMed will be given. 32
International Journal of Trichology / Jan-Mar 2015 / Vol-7 / Issue-1
Copyright of International Journal of Trichology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
