Abstract
Introduction
Pseudofolliculitis barbae (PFB) is a chronic inflammatory condition of hair follicles characterized by inflamed papules and pustules, with increased risk in individuals with curly or coarse hair. While psychiatric comorbidities in acne are well studied, limited research exists on PFB's psychological impact.
Methods
We conducted a cross-sectional analysis of individuals with PFB using the All of Us dataset, which includes EHR data from US adults since 2018.
Results
A total of N = 1,668 individuals were included in the matched dataset, with 834 PFB cases and 834 controls and were assessed for diagnosis of attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), major depressive disorder (MDD), and general anxiety disorder (GAD). The association between the presence of ADHD and PFB was significant (p value = 0.009). Similarly, the presence of GAD (23% of PFB patients and 10% of patients without PFB) and MDD (48.4% of PFB patients and 26.3% of patients without PFB) was significantly associated with the presence of PFB (p value <0.001 for both conditions). However, OCD was found not to be significantly associated with the presence of PFB (p = 0.15).
Discussion
Our study demonstrated a significant association between PFB and mood disorders like depression or anxiety. Future studies should examine PFB severity and treatment efficacy on psychological outcomes.
Keywords: Pseudofolliculitis barbae, Mental health, Anxiety
Introduction
Pseudofolliculitis barbae (PFB) is a chronic inflammatory condition that occurs when hair follicles re-enter the skin, often secondary to shaving. It is primarily characterized by inflamed papules and pustules, with increased risk in individuals with curly or coarse hair [1]. Complications include post-inflammatory hyperpigmentation, infections, and keloids. While psychiatric comorbidities in acne are well studied, limited research exists on PFB's psychological impact. This study examines associations between PFB and obsessive-compulsive disorder, attention-deficit/hyperactivity disorder (ADHD), major depressive disorder, and general anxiety disorder using the National Institutes of Health’s All of Us dataset, a diverse biomedical database enabling robust analysis across different demographic groups.
Methods
We conducted a cross-sectional analysis using the All of Us dataset, which includes EHR data from US adults since 2018. The PFB cohort included individuals with at least one ICD diagnosis code for PFB (ICD10CM-L73.1, SNOMED399205006), with no PFB diagnosis as controls. We used propensity score matching with the optimal pairs method to match PFB cases to controls 1:1 based on race, ethnicity, sex, and age.
Results
A total of N = 1,668 individuals were included in the matched dataset, with 834 PFB cases and 834 controls (see Table 1 and Table 2). In matched data, 56.6% were female, 14.0% were Hispanic or Latino, 37.4% were Black or African American, 37.6% were white, 1.3% were Asian, 7.6% identified as “more than one population,” and 16.1% were unknown. The difference in age was not significant (p = 0.9988), with a mean age of 53.6 (SD = 15.7) for participants with PFB and 53.6 (SD = 15.7) for those without PFB. Association between the presence of ADHD and PFB was significant (p value = 0.009) (see Table 2). Among patients with PFB, ADHD was present in 8.0% vs. 4.8% in controls. Similarly, the presence of general anxiety disorder (23% of PFB patients and 10% of patients without PFB) and major depressive disorder (48.4% of PFB patients and 26.3% of patients without PFB) was significantly associated with the presence of PFB (p value <0.001 for both conditions). However, OCD was found not to be significantly associated with the presence of PFB (p = 0.15).
Table 1.
Unmatched demographic characteristics
| | PFB diagnosis (N = 834) | No PFB diagnosis (N = 627,830) | p value |
|---|---|---|---|
| Age | |||
| Mean (SD) | 53.6 (15.7) | 55.6 (16.9) | p < 0.001 |
| Median (Q1,Q3) | 54 (40.2, 65) | 57 (41, 69) | |
| Sex, N (%) | |||
| Male | 350 (42.0) | 228,302 (36.4) | p = 0.001 |
| Female | 472 (56.6) | 393,308 (62.6) | |
| Unknown | 12 (1.4) | 6,220 (1.0) | |
| Race, N (%) | |||
| Asian | 11 (1.3) | 22,306 (3.6) | p < 0.001 |
| Black or African American | 312 (37.4) | 99,188 (15.8) | |
| More than one population | 63 (7.6) | 30,804 (4.9) | |
| White | 314 (37.6) | 353,447 (56.3) | |
| Unknown | 134 (16.1) | 122,085 (19.4) | |
| Ethnicity, N (%) | |||
| Hispanic or Latino | 117 (14.0) | 112,344 (17.9) | p = 0.005 |
| Not Hispanic or Latino | 686 (82.3) | 497,915 (79.3) | |
| Unknown | 31 (3.7) | 17,571 (2.8) | |
Table 2.
Demographics and psychiatric comorbidities among matched patients with PFB
| | PFB diagnosis (N = 834) | No PFB diagnosis (N = 834) | p value |
|---|---|---|---|
| Age | |||
| Mean (SD) | 53.6 (15.7) | 53.6 (15.7) | p = 0.9988 |
| Median (Q1,Q3) | 54 (40.2, 65) | 54 (40.2, 65) | |
| Sex, N (%) | |||
| Male | 350 (42.0) | 350 (42.0) | 1a |
| Female | 472 (56.6) | 472 (56.6) | |
| Unknown | 12 (1.4) | 12 (1.4) | |
| Race, N (%) | |||
| Asian | 11 (1.3) | 11 (1.3) | 1a |
| Black or African American | 312 (37.4) | 312 (37.4) | |
| More than one population | 63 (7.6) | 63 (7.6) | |
| White | 314 (37.6) | 314 (37.6) | |
| Unknown | 134 (16.1) | 134 (16.1) | |
| Ethnicity, N (%) | |||
| Hispanic or Latino | 117 (14.0) | 117 (14.0) | 1a |
| Not Hispanic or Latino | 686 (82.3) | 686 (82.3) | |
| Unknown | 31 (3.7) | 31 (3.7) | |
| Psychiatric comorbidity, N (%) | |||
| Mood disorders | |||
| Generalized anxiety disorder | 192 (23.0) | 83 (10.0) | <0.001 |
| Major depressive disorder | 404 (48.4) | 219 (26.3) | <0.001 |
| Hyperkinetic disorders | |||
| ADHD | 67 (8.0) | 40 (4.8) | p = 0.00937 |
| OCD | 16 (1.9) | 8 (1.0) | p = 0.15 |
aSince matching was performed based on race, ethnicity, and sex, they will have p value = 1.
Discussion
Our study demonstrated a significant association between PFB and mood disorders like depression or anxiety. This aligns with findings in pigmentary disorders, where increased odds of depression and anxiety were observed [2]. Visible skin lesions can impact self-esteem and body image, triggering behaviors like skin picking, which are associated with low self-esteem and impaired quality of life [3, 4]. This can create a cycle wherein skin picking worsens hyperpigmentation and scarring, reinforcing compulsive grooming. Additionally, hair removal techniques such as plucking may contribute to PFB by increasing the risk of ingrown hairs, particularly in Black and Asian women [5].
This study highlights the need for a multidisciplinary approach that combines dermatologic treatment with behavioral interventions to address compulsive skin manipulation. The use of the All of Us database is limited by its reliance on data derived from electronic health records. This study is limited by its cross-sectional database, and causal conclusions cannot be drawn. Limitations may include poor documentation of PFB severity or treatment impact, inaccurate diagnosis coding, and residual confounding. Future studies should examine PFB severity and treatment efficacy on psychological outcomes.
Acknowledgments
We gratefully thank All of Us participants for their contributions, without whom this research would not have been possible. We also thank the National Institutes of Health’s All of Us Research Program for making available the participant data examined in this study.
Statement of Ethics
The study is a secondary analysis of an existing dataset and is exempt by the NYU Langone IRB Committee from requiring ethics approval.
Conflict of Interest Statement
This study was an analysis of an existing database of patients of whom consent was taken by the NIH All of Us Program. Additional patient consents were not required for this study. The authors have no conflicts of interest to declare.
Funding Sources
This study was not supported by any sponsor or funder.
Author Contributions
Olagun-Samuel: conceptualization, data curation, formal analysis, investigation, methodology, project administration, and writing – original draft, review, and editing. Ahuja: conceptualization and writing – original draft, review, and editing. Manduca: writing – review and visualization. Mandal and Friedman: methodology, validation, visualization, and formal analysis. Ristianto: data curation, formal analysis, and validation. Adotama: conceptualization, project administration, writing – review, supervision, and methodology.
Funding Statement
This study was not supported by any sponsor or funder.
Data Availability Statement
All data analyzed this study used data from the All of Us Research Program’s registered Tier Dataset v8, which are openly available to authorized users on the Researcher Workbench. Further inquiries can be directed to the corresponding author.
References
- 1. Ogunbiyi A. Pseudofolliculitis barbae; current treatment options. Clin Cosmet Investig Dermatol. 2019;12:241–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Kamal K, Xiang DH, Young K, Mostaghimi A, Barbieri JS, Cohen JM, et al. Comorbid psychiatric disease significantly mediates increased rates of alcohol use disorder among patients with inflammatory and pigmentary skin disorders: a case-control study in the all of us research Program. Arch Dermatol Res. 2024;316(2):79. [DOI] [PubMed] [Google Scholar]
- 3. Ekore RI, Ekore JO. Excoriation (skin-picking) disorder among adolescents and young adults with acne-induced postinflammatory hyperpigmentation and scars. Int J Dermatol. 2021;60(12):1488–93. [DOI] [PubMed] [Google Scholar]
- 4. Sampaio DG, Grant JE. Body-focused repetitive behaviors and the dermatology patient. Clin Dermatol. 2018;36(6):723–7. [DOI] [PubMed] [Google Scholar]
- 5. Winter H, Schissel D, Parry DAD, 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 Dermatol. 2004;122(3):652–7. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data analyzed this study used data from the All of Us Research Program’s registered Tier Dataset v8, which are openly available to authorized users on the Researcher Workbench. Further inquiries can be directed to the corresponding author.