DISCUSSION

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Our patient developed robust folliculitis in the treatment area within a week of each Nd:YAG treatment. We hypothesize that the mechanism driving this folliculitis is similar to that of pseudofolliculitis barbae (PFB), which is a chronic disorder that often manifests as inflammatory papulopustules in the beard area.5,6 PFB is caused by a foreign body inflammatory response to curved hair re-entering the skin, often after shaving; it is particularly common in African American men and individuals with curly, coarse hair.5-7 During laser hair removal, the hair follicle is destroyed through the process of photothermolysis, with the residual hair shaft extruded through the skin over time.7,8 The posttreatment folliculitis sometimes observed with this procedure might be the result of a foreign-body inflammatory reaction to the hairs being lost through extrusion, similar to the process observed with PFB. As seen in our patient, once the depilatory effect is complete, the nidus for the foreign body response is gone and the folliculitis resolves.

Laser hair removal has shown promise as a therapy for PFB, acne keloidalis nuchae, hidradenitis suppurativa, and pilonidal disease and is generally well tolerated;6,9-13 however, posttreatment folliculitis has been reported as a side effect.1,4,14 It is currently unclear which patient populations are more likely to develop this laser-induced folliculitis. If the pathophysiology is similar to that of PFB, then African American men or individuals with coarse, dark hair and pili multigemini hairs might have an increased risk of developing folliculitis with laser therapy. Our patient developed a robust folliculitis after laser treatment, likely due to his coarse hair and pili multigemini hairs. In individuals who are known to develop folliculitis after laser hair removal, have numerous pili multigemini hairs, or have a history of irritant folliculitis secondary to shaving, it might be reasonable to pretreat with topical steroids and oral doxycycline. The use of prophylactic fluocinonide cream and doxycycline along with gentle washing significantly reduced the severity and duration of folliculitis in the case presented here. While this reaction might be unavoidable in some individuals, the anti-inflammatory effects of steroids and doxycycline combined with the depilatory effect of gentle washing with a clean cloth will likely improve laser-induced folliculitis. By offering patients who are prone to this side effect a reasonable pretreatment regimen, laser therapy will remain a tolerable and effective treatment option for those seeking cosmetic hair removal and therapy for PFB, hidradenitis suppurativa, and other conditions.11-13,15

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