A 35-year-old man comes to the office due to painful bumps on his neck. For the last 6 months, he has had a progressive rash on his anterior neck that has not improved with over-the-counter emollients. Medical history is unremarkable. Vital signs are within normal limits. Skin examination findings are as shown: The remainder of the examination is normal. Which of the following is the most appropriate management for this patient's skin condition?

Question

A 35-year-old man comes to the office due to painful bumps on his neck.  For the last 6 months, he has had a progressive rash on his anterior neck that has not improved with over-the-counter emollients.  Medical history is unremarkable.  Vital signs are within normal limits.  Skin examination findings are as shown:  The remainder of the examination is normal.  Which of the following is the most appropriate management for this patient's skin condition?

Quizplus · Accepted Answer

Explanation: This patient has small, painful papules in the beard area consistent with pseudofolliculitis barbae (PB). PB is caused by penetration of the hair shaft into interfollicular skin, either through the lateral wall of the follicle (transfollicular penetration) or by curving back down into the skin after exiting the follicle (extrafollicular penetration). PB occurs in all ethnic groups but is most prevalent in black men who have tightly curled facial hair. Shaving with a multiblade razor, which cuts hair below the skin surface and leaves an angled tip to the hair shaft, further increases the risk. The diagnosis of PB is usually apparent on clinical presentation. Complications include hyperpigmentation, secondary bacterial infection, and (occasionally) keloid formation. Discontinuation of shaving is first-line treatment and results in improvement in a few weeks. Subsequently, adjustment of shaving routine (eg, single blade, warm compresses prior to shaving) or use of alternative shaving methods (eg, hair clippers to leave hair longer) can be adopted. Chemical depilatories, laser hair removal, and topical eflornithine (which slows hair growth) can also be used. (Choice A) Benzoyl peroxide is used for inflammatory acne, which can present with small, tender papules on the neck but usually also involves the upper face and most commonly presents in the adolescent years. (Choice B) Oral terbinafine is used for treatment of tinea barbae, which can present with papules in the beard area but is typically scaly or pustular, often pruritic, and frequently occurs in an annular pattern. (Choice C) Imiquimod is most commonly used for treatment of anogenital warts, superficial basal cell carcinoma, and actinic keratosis. Although actinic keratosis can present with multiple facial papules, the lesions are typically scaly and located in the scalp and upper face, and the disorder is relatively uncommon in dark-skinned patients. (Choice D) Although PB can be complicated by secondary bacterial infection, bacterial folliculitis presents acutely with localized erythema and pustule formation. Educational objective: Pseudofolliculitis barbae presents with small, painful papules in the beard area. It is caused by penetration of the hair shaft into interfollicular skin, often due to shaving of tightly curled hair. Complications include hyperpigmentation, secondary bacterial infection, and keloid formation. Management includes discontinuation of shaving or using clippers to cut hair farther from the skin surface. References: Pseudofolliculitis barbae: a review of current treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/30909328)

A 35-Year-Old Man Comes to the Office Due to Painful