Abstract
This survey study describes an opportunity for a partnership between barbers and dermatologists to identify, evaluate, and treat pseudofolliculitis barbae in the Black male population.
Pseudofolliculitis barbae (PFB) is a chronic inflammatory follicular disorder that primarily affects males of African descent due to traumatic shaving practices.1 Inherent differences in the skin and hair of these individuals have implications for disease outcomes, and sociodemographic characteristics may be factors in delayed care.2 It is important to consider the interplay between cultural skin or hair care practices and the natural disposition of curly hair as a multifactorial cause for this disease process.
Barbershops are recognized as cultural safe havens and community hubs for Black men and a potential opportunity for health care intervention.3 Barbers can facilitate hair care practices that mitigate the development of severe PFB.3 We investigated the effectiveness of an educational intervention as a pilot for allyship between barbers and dermatologists to address gaps in PFB care.
Methods
Barbers, identified via a web search of the greater Houston, Texas, area, were provided the 20-item preintervention and postintervention questionnaire to assess their ability to recognize PFB, recommend proper treatment, and ascertain when dermatologic evaluation was needed. Data were collected from January to April 2022. After the pretest survey, a comprehensive educational pamphlet on the recognition, cause, prevention, and treatment of PFB was reviewed with each barber; common myths and nuanced home remedies from barber experience were also addressed. Participants were given the pamphlet to keep for reference or supply to patrons as needed. One to 2 weeks after the educational session, each barber was evaluated under supervision via a posttest questionnaire, identical to the pretest survey (Supplement 1). The University of Texas Medical Branch, Galveston Institutional Review Board approved this survey study and waived the informed consent requirement because the data were deidentified and could not be linked to participants.
Two-sample, paired t test was used for means of preintervention and postintervention scores. P < .001 indicated statistical significance. Data analysis was performed with SAS 9.4 (SAS Institute Inc).
Results
Of the 40 barbers surveyed, 39 (97.5%) identified as Black individuals, 1 (2.5%) as a Hispanic individual, 30 (75.0%) as males, and 10 (25.0%) as females, with a mean age of 34.3 (based on weighted mean). Thirty-six barbers (90%) noted having a 60% or greater Black clientele (Table 1).
Table 1. Basic Characteristics of Barbers Completing Pseudofolliculitis Barbae Survey and Educational Intervention.
| Characteristic | No. (%) |
|---|---|
| Total participants | 40 (100) |
| Age, median (IQR), y | |
| 18-25 | 7 (17.5) |
| 26-35 | 18 (45.0) |
| 36-45 | 8 (20.0) |
| 46-55 | 7 (17.5) |
| Sex | |
| Male | 30 (75.0) |
| Female | 10 (25.0) |
| Race and ethnicitya | |
| Black | 39 (97.5) |
| Otherb | 1 (2.5) |
| Years of experience as a barber | |
| 0-9 | 25 (62.5) |
| ≥10 | 15 (37.5) |
| Percentage of Black clients | |
| 0-20 | 1 (2.5) |
| 21-40 | 0 |
| 41-60 | 3 (7.5) |
| 61-80 | 12 (30.0) |
| 81-100 | 24 (60.0) |
Race and ethnicity were self-reported in the questionnaire.
Other included Hispanic or Latinx.
Among pretest questions, responses showed nearly unanimous participant understanding (39 [97.5%]) that Black males were the group most affected by PFB and severe forms of PFB should be evaluated by a physician. Twelve barbers (30.0%) correctly identified the PFB photograph in the pretest survey compared with 39 barbers (97.5%) in the posttest survey (Table 2). Only 2 barbers (5.0%) in the pretest survey recognized laser hair removal as the most effective treatment for PFB vs 37 barbers (92.5%) in the posttest survey. Mean (SD) percentage of correct score out of 20 questions was 54.8% (12.4% [n = 10.95]) in the pretest survey compared with 91.0% (8.4% [n = 18.2]) in the posttest survey, a significant difference (P < .001) in scores. Median (IQR) score was 55% (45%-65%) for the pretest survey and 90% (85%-100%) for the posttest survey.
Table 2. Survey Questions Assessing Knowledge and Recommendations Related to Pseudofolliculitis Barbae (PFB) Among Barbers (N = 40).
| Survey questions and responses | Answers, No. (%) | |
|---|---|---|
| Pretest survey | Posttest survey | |
| What skin condition is this?a | ||
| d. Pseudofolliculitis barbae | 12 (30.0) | 39 (97.5) |
| What causes the skin condition in the previous question? | ||
| b. Hair curving back into skin causing inflammation | 8 (20.0) | 35 (87.5) |
| Where is the most common location to find the skin condition above? | ||
| c. The jawline | 27 (67.5) | 40 (100) |
| What are some complications of the skin condition above? | ||
| f. All of the above (hyperpigmentation, scarring, hair loss, keloids, itching) | 32 (80.0) | 38 (95.0) |
| What gender can get the skin condition above? | ||
| c. Both (men and women) | 21 (52.5) | 37 (92.5) |
| What male ethnic demographic suffers from this skin condition most commonly? | ||
| c. Black or African American | 39 (97.5) | 40 (100) |
| What contributes to the progression of this disease? | ||
| b. Repetitive shaving with razors | 10 (25.0) | 34 (85.0) |
| When a client with this condition is in your chair and has no preference to be shaven or not, which of the recommendations below should be made to prevent progression? | ||
| c. Avoid cutting their hair altogether for a month | 30 (75.0) | 36 (90.0) |
| When a client with this condition is in your chair and wants to be clean shaven, which of the recommendations below should be made to prevent progression? | ||
| b. Shave using electric clippers | 26 (65.0) | 37 (92.5) |
| If you use electric clippers, how should you shave the client? | ||
| b. Shave with the grain | 22 (55.0) | 36 (90.0) |
| What length of hair is recommended to retain when shaving? | ||
| b. 1-3 mm | 20 (50.0) | 32 (80.0) |
| What are the potential consequences of using manual razors in this skin condition? | ||
| c. The skin worsens | 36 (90.0) | 34 (85.0) |
| If the client wants to be clean shaven, how should you counsel the client to take care of this issue at home? | ||
| b. Advise to shave using clippers every other day | 8 (20.0) | 23 (57.5) |
| If the client demands a manual razor, what steps can be taken while the client is in the chair to prevent this skin condition? | ||
| a. Place shaving cream on the client’s face prior to shaving | 3 (7.5) | 0 |
| b. Place a damp hot towel on the client’s face before shaving | 3 (7.5) | 0 |
| e. Both a and bb | 30 (75.0) | 39 (97.5) |
| Should clients with mild forms of this skin condition see a physician? | ||
| a. Yes | 25 (62.5) | 40 (100) |
| Should clients with severe forms of this skin condition see a physician? | ||
| a. Yes | 39 (97.5) | 40 (100) |
| What type of physician would you recommend this client to go see? | ||
| d. Dermatologist | 20 (50.0) | 40 (100) |
| If a client would like to retain beard growth and has active disease, what do physicians recommend as the most effective treatment for this skin condition? | ||
| a. Stop shaving for 4 weeks or more | 5 (12.5) | 1 (2.5) |
| b. Use prescription topical medicine | 4 (10.0) | 0 |
| c. Both a and bb | 30 (75.0) | 35 (87.5) |
| What do physicians recommend as the ABSOLUTE most effective for preventing this skin condition regardless of shaving preference? | ||
| e. Laser hair removal | 3 (7.5) | 37 (92.5) |
| What do physicians recommend as the ABSOLUTE most effective treatment for this skin condition regardless of shaving preference? | ||
| e. Laser hair removal | 2 (5.0) | 37 (92.5) |
Participants were shown a photograph of pseudofolliculitis barbae.
Correct answer.
Discussion
Dermatologists have proposed partnering with barbershops to bridge access gaps and provide more opportunities for care in the Black male population.3,4,5 Educating barbers on dermatologic conditions that disproportionately affect Black males and establishing referral services between barbers and dermatologists could serve as plausible interventions.4 Study results showed that educational intervention targeted at barbers was associated with increased knowledge regarding the causes, prevention, and treatment of PFB. Further research and implementation of these interventions are needed in efforts to improve health outcomes.
Study limitations included heterogeneity in response options, which may skew correct responses, potentially introducing bias. Given the lack of evidence on optimal treatment strategies for PFB, there may be some uncertainty about the correct answers for the survey, which could be factors in response variability.
eAppendix
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eAppendix
Data Sharing Statement
