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A new US Army directive issued on July 7 — requiring all soldiers to be clean shaven while on duty unless they have an approved religious accommodation to keep a beard — may pose problems for some men, including those with the skin condition pseudofolliculitis barbae, dermatologists said.

The new directive follows an order issued in March by Secretary of Defense Pete Hegseth, calling for a review of existing standards related to physical fitness, body composition, and grooming, including beards.

About 40,000 medical waivers to pause shaving have been issued to members of the Army, including active soldiers, National Guard, and Reserves, Major Travis Shaw, an Army spokesperson, told Medscape Medical News. He had no details on how many of those were permanent vs temporary medical waivers (called profiles by the Army) or a breakdown of the severity of the conditions necessitating the waiver request. Mustaches are authorized, and the directive does not apply to those with an approved religious accommodation.

Other than that, “as of July 7, no more permanent waivers will be issued,” Shaw said. Next is a 90-day reassessment period, he noted. Those who have a temporary or permanent medical waiver for shaving will be reassessed by their medical provider, who will determine if continuation of the profile and a written exception to policy is needed to pause shaving temporarily. If necessary, a medical treatment plan will be created, and the provider will provide an expected recovery time. The treatment plans will take into account whether the condition is mild, moderate, or severe.

Soldiers will be encouraged to work with their medical provider and their commander to comply, Shaw said. Those who don’t face possible separation from the Army.

For cases not responsive to the shaving pauses and medical treatment plans, referrals to specialty care and more targeted treatment such as laser treatment are possible. Laser treatment may be government-funded, according to the directive.

No one has yet requested laser treatment, Shaw said, but he noted that the process of assessment is at its earliest stages.

Under the directive, “soldiers must comply with the facial hair standard within 2 years but cannot be on profile more than 12 accumulated months,” Shaw said. “Administrative separation (discharge) may be considered thereafter.”

About Pseudofolliculitis Barbae 

Pseudofolliculitis barbae , also known as razor bumps, is a common reason soldiers request medical waivers, so they don’t have to shave. Those with darker skin are more likely to be affected, as are those with naturally curly hair. The condition occurs in up to 60% of Black men and can also affect women.

In individuals prone to the condition, “as the hair grows out and reaches a certain length, it curls back into the skin,” Adam Friedman, MD, professor and chair of dermatology at George Washington University School of Medicine and Health Sciences, Washington, DC, said in an interview.

“The body doesn’t look on it as your hair, it looks on it as a foreign object,” and bumps, which can look like acne, occur, he said. “Shaving will cause more injury and more inflammation,” he added. “As you hit those bumps, that creates an inflammatory response.”

As time goes on, the bumps can become scars, Friedman said, who has treated patients who have subsequently developed keloids. The condition is both painful and disfiguring, he noted.

Careful Shaving Technique

To prevent exacerbation of pseudofolliculitis barbae, Andrew Alexis, MD, MPH, professor of clinical dermatology and vice chair for diversity and inclusion at Weill Cornell Medicine, New York City, provides his patients with detailed instructions on shaving, including preparation and post-shaving care.

“For men who use a manual razor, the beard area should be prepared by washing with gentle cleanser and applying a hydrating shaving gel or cream prior to shaving,” Alexis told Medscape Medical News. “For manual razors, I recommend specific razors that are designed to minimize irritation and re-entry of the hair shafts into the skin (intra- and extra-follicular penetration). Shaving should be done with the grain and without pulling the skin taut.”

After shaving, he recommends application of topical clindamycin or desonide, depending on the severity of the condition. Using an electric razor with a straight edge (clippers) is an alternative for men who are comfortable having a mild stubble, he said.

Topical, Laser Treatments

According to Alexis, clindamycin-benzoyl peroxide gel has demonstrated efficacy in one vehicle-control study.“Topical retinoids can be useful in my experience,” he said. And for those who don’t respond, laser treatment can be tried, both Alexis and Friedman agreed.

“Laser hair removal is curative because you destroy the hair,” Friedman explained. However, it typically requires five or six treatments to be effective, he said. And problems can arise if a doctor doesn’t use the right type of laser, he said.

Nd:YAG laser therapy has proven effective in reducing the papules and pustules associated with pseudofolliculitis barbae, and some research has found that adding topical eflornithine cream to the laser treatment has an additive effect on reducing hair and inflammatory papules.

“I use the 1064nm Nd:YAG, which has demonstrated safety and efficacy in patients with higher Fitzpatrick skin phototypes,” Alexis said.

Laser hair removal is typically not covered by insurance, Friedman said. (In the directive, the Army said coverage of elective laser hair removal, if deemed necessary, may be possible.

Friedman and Alexis had no relevant disclosures.