In the world of aesthetic practice, we are aware of the need to understand the differences in treating skin of colour (SOC) patients with various modalities. Physiological differences in skin and hair mean conditions present differently and adjustments to treatment may be required for better outcomes.
Folliculitis is a common skin condition that many people experience throughout their lives. There are many different types of folliculitis, and each type is unique, depending on the cause, symptoms and appearance. Think of folliculitis as a generic term – it’s a family of conditions. Studies have suggested that different ethnicities have varying impacts to skin infections like folliculitis as well as a suspectability to them.1
In this article, we will discuss the different types of folliculitis and approaches to management in treating SOC.
The anatomical makeup of skin varies amongst different ethnicities.1 Afro-Caribbean hair is thought to be curlier to coiled with oval to elliptical hair follicles, Asian hair is more likely to be straight to wavy with round to slightly oval-shaped follicles, and Caucasian hair is more straight to curly with oval-shaped follicles.2,3 Afro-Caribbean skin has a thicker epidermis and a compact dermis leading it to have a higher skin barrier function.4 Subsequently, it is easily inflamed and more prone to pigmentation and scarring. Lowest ceramide levels correlate to the highest epidermal water loss seen in Afro-Caribbean skin.5 Afro-Caribbean skin has higher levels of sebaceous glands and three times more apocrine sweat glands. More compact collagen fibres, fibroblasts and less elastosis are common in SOC as they have a more compact dermis. As well as a very convoluted dermal-epidermal junction, this may explain the reduced signs of photoageing in Afro-Caribbeans.6
The main cause of folliculitis is a fungal or bacterial infection at the top of the hair follicle.7 In most cases, the main symptom of folliculitis is a red bump on the skin that looks like a pimple. These pus-filled bumps are usually riddled with ingrown hairs and are often surrounded by pink to red inflamed skin. Pimples may appear on the skin in groups or on large areas of the beard, arms, back, buttocks and legs. Irritation and excessive sweating can trigger folliculitis.
Folliculitis begins with the introduction of skin pathogens into the hair follicles. The condition is contagious, and people can pass it on to others through close skin-to-skin contact. Folliculitis can develop into more serious skin conditions, such as cellulitis or abscesses if left unattended or not treated correctly.7 If practitioners are unsure about a skin condition or if it’s beyond the scope of their practice, then referral to a specialist should be considered.
It is commonly caused by Staphylococcus aureus which naturally lives on our skin.8 The condition can also be caused by Pseudomonas from shared baths and contaminated water. The herpes simplex viruses from cold sores can also lead to herpetic folliculitis. Oil folliculitis is an inflammation of the hair follicles due to exposure of various oils and usually occurs on the forearms or thighs.8
Fungal folliculitis caused by Malassezia, previously known as pityrosporum folliculitis, can result in an itchy acne-like eruption affecting the upper body and face. Pimples can appear in areas including the forehead, down the hairline and on the upper back. As it is similar in appearance, pityrosporum folliculitis is often mistaken for acne vulgaris. Treatment failure or exacerbation should make you question the diagnosis and consider folliculitis as a potential differential. People are more likely to confuse guttate or pustular psoriasis with folliculitis because all these conditions cause patches to appear on the skin.9
Also known as keratosis follicularis, lichen follicularis, or colloquially ‘chicken skin’, keratosis pilaris is a very common condition that is seen widely.10 It is characterised by small, rough bumps on the hair follicles, caused by an overproduction of keratin. The accumulation of keratin forms a ‘keratin plug’ that blocks the opening of the hair follicle. This causes the hair follicles to expand under the skin, creating bumps on the skin’s surface. It causes dry, rough patches and small bumps, often on the shoulders, thighs, cheeks or buttocks. Although follicular keratosis can appear on different parts of the body, the condition is easy to recognise due to its tiny size.10
Keratosis follicularis slightly resembles the rough skin of a chicken, hence the name. In Caucasian skin, keratosis follicularis is usually characterised by white or red bumps, while darker brown bumps may be seen in darker skin tones. Although keratosis follicularis is a benign disease, it is associated with significant aesthetic comorbidity, with 69% of patients reporting discomfort due to rash.11 This is of particular concern given that keratosis follicularis most commonly occurs in adolescent women, with the potential to impact self-esteem and body image.
As per the name, pseudo folliculitis is a mimic of true folliculitis. Known as pseudofolliculitis barbae when it affects the beard, it the most common form of folliculitis seen in adult males.2 An inflammatory response is triggered by irritation to the hair follicle through shaving, plucking, waxing, electrolysis or the way hair regrows. Shaving against the grain, thick hair, uncut beards or wearing clothing that rubs against the skin can be risk factors. The area may be itchy, and papules can appear with an ingrowing hair. It is most commonly seen in patients of colour due to the more tightly curved hairs, but can affect all ages and races.12
When hair follicles are damaged, they are more susceptible to infection. In most cases of folliculitis of the scalp, there is resolution without antibiotics or any lasting scarring, however, in folliculitis decalvans this is not the case.13 It can affect small patches or larger areas over time. More severe cases of folliculitis decalvans can lead to complications such as scarring, or permanent hair loss. The cause is not well understood, and it is suspected to be S. aureus alongside predisposing factors such as a weak immune system. It affects both sexes, but men can be affected from as early as adolescence whilst women tend not to be until their 40s.14 Though no published studies are available, African-American women are said to be disproportionality affected.3
Clinically, patients present with round patches of erythematous or cicatricial alopecia on the vertex or occipital areas. Pustules and crusting are usually seen as well as erosions.15 As the follicle is completely destroyed, the hair is shed, leaving a scar tissue behind. Scars on the scalp lead to permanent hair loss as new hair does not grow through the scar tissue without a hair follicle.4 This can lead to significant psychological stress.
Acne keloidalis nuchae
Also known as folliculitis keloidalis nuchae, the tell-tale sign is scarring at the nape of the neck. It is more common between 14 and 25 years of age and in men with curly hair.16 The condition is prevalent in Afro-Caribbeans and is rarely seen in Caucasians due to the anatomical differences in hair and skin.
A chronic inflammatory process with follicular papules or pustules leads to hair loss in the affected areas. The hypertrophic scarring may fuse into a band or plaques just below the hairline. Close shaving of the neck can worsen the condition as curved hairs can get caught beneath the skin or attempt to re-enter the skin, triggering an inflammatory response. Shirt collars can also exacerbate the problem.17
Principles of management
Patients should avoid shaving for three months or longer, as well as reducing how often they shave. It is advised for patients to use an electric razor or a single blade for a wet shave to reduce irritation. Patients should shave in the direction of the hair grain and avoid stretching the skin, as this can exacerbate the condition. They should aim to leave stubble of at least 1mm to avoid hair retracting into follicles or curling back to pierce the skin.18 I advise my patients to avoid anything rubbing around the beard or neck area such as high collars or helmets, as well as avoiding the use of greasy hair products or pomades until resolution.19
The use of topical antiseptics as a soap substitute can help with folliculitis and, when applied regularly, can regularly can reduce secondary infections as well as soothe irritation.18 Patients can apply a mild potency steroid immediately after shaving which can help the condition. Where a fungal infection may be suspected, I advise treatment with an anti-fungal cream and shampoo as frequently as possible until resolution, followed by once or twice weekly maintenance as fungal infections can often recur.18 Key ingredients in cosmeceuticals can also help folliculitis conditions. Azelaic acid has been shown to improve hyperkeratosis and roughness by 92%.20 Salicylic acid can help pigmentation and roughness by 52% and lactic acid can improve pigmentation and roughness by 66%.21
For hypertrophic scarring in acne keloidalis nuchae, super-potent topical steroid creams can be applied daily under observation.22 Steroid-impregnated plaster has been shown to be effective due to better adherence and controlled dosage.23
When there is no response to topical treatment or if the condition is severe, a three-month course of tetracycline antibiotic can be used acting as an anti-inflammatory. If there is still poor or no response, a swab may be necessary and escalation of antibiotic therapy. Conditions such as folliculitis decalvans may need dual antibiotic therapy with rifampicin 300mg BD with clindamycin 300mg BD.6
Laser hair removal can help address folliculitis in areas where hair may not be desired. In severe cases, this may even be considered on the scalp and face. Hypertrophic and keloid scarring can improve with steroid injections and laser every four-six weeks.25 If there has been no or little improvement, surgical excision can be considered with further steroid injections to minimise recurrence.7
Different ethnicities are more pre-disposed to different forms of folliculitis, and SOC patients are predisposed to poorer cosmetic outcomes due to their tendency for pigmentation and scarring. The lack of concrete evidence in treating the cosmetic outcomes in SOC can only be overcome with more widespread advocacy and research by practitioners and patients alike.
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15. Fabris, Mariana Rocha, Clarisse Pereira Melo, and Daniel Fernandes Melo, "Folliculitis Decalvans: The Use Of Dermatoscopy As An Auxiliary Tool In Clinical Diagnosis", Anais Brasileiros De Dermatologia, 2013, <https://doi.org/10.1590/abd1806-4841.20132129>
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