Although about 5 million Black people in the US have severe pseudofolliculitis barbae (PFB), with fewer Asian, Hispanic, and White people affected, no guidelines for the care of these patients have been established until now.

Just published is a consensus statement on best practices for diagnosing and managing PFB, based on a three-round Delphi Consensus Study conducted between November 2025 and February 2026.

PFB — also known as razor bumps — is a chronic inflammatory disease caused by the penetration of shaved, curved hair shafts into the skin, affecting mostly men. It presents as follicular or perifollicular papules that can be accompanied by pustules, hyperpigmentation, and scarring.

“We hope it will have an impact,” said Simona Alomary, the first author on the paper, published in JAMA Dermatology, and a Skin of Color research fellow at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, while the report was underway. She is now a fourth-year medical student at Rutgers New Jersey Medical School in Newark, New Jersey. Susan Taylor, MD, professor of dermatology at the University of Pennsylvania, is the senior author.

“It’s going to be useful for physicians to confirm their approach” to managing PFB, Alomary told Medscape Medical News.

‘Long Overdue’

“These recommendations are long overdue, and frankly, they address a condition that has been hiding in plain sight for decades,” Adam Friedman, MD, professor and chair of dermatology at The George Washington University School of Medicine and Health Sciences in Washington, DC, told Medscape Medical News. Use of the nonmedical term “razor bumps,” he said, minimizes what can be a “chronic, painful, disfiguring inflammatory skin disease with very real psychosocial and professional consequences.”

Friedman, who was not involved in the guidelines and was asked to comment, cited the need to recognize that PFB is a chronic disease.

The Process

The researchers curated more than 100 studies on PFB down to the 41 references listed in the guidelines. The Delphi panelists included 13 board-certified dermatologists, including two in the military. Of the 13, eight were in private practice and five in academics; they practiced in the North, South, Midwest, and West.

The statements address diagnostic criteria and assessment, behavioral modification and hair removal, topical and systemic therapy, procedural therapy, and occupational considerations. Consensus was defined as greater than or equal to 75% agreement.

Overall, 40 statements reached consensus, including the following:

• Dermoscopy may help monitor treatment response over time and, as an adjunct, to confirm ingrown hairs and educate patients.
• Behavioral modification includes avoiding shaving during acute flares.
• If shaving is needed, electric clippers or trimmers are preferred, leaving 0.5 to 1 mm of hair.
• For razor shaving, single-blade razors may be preferred.
• Topical therapy with benzoyl peroxide, 5%, and clindamycin, 1%, is recommended for inflammatory papules and pustules.
• Short course, low-potency topical corticosteroids may help acute inflammatory flares.
• Topical retinoids and triple-combination cream (fluocinolone, 0.01%; hydroquinone, 4%; tretinoin, 0.05%) may improve hyperkeratosis and postinflammatory hyperpigmentation.
• Systemic therapy with oral tetracyclines (usually doxycycline) is a first-line systemic treatment for moderate-to-severe PFB.
• Laser hair removal is a disease-modifying treatment. (The neodymium-doped yttrium aluminum garnet laser is appropriate for Fitzpatrick skin types III-VI. For types I-III, a pulsed Alexandrite laser is appropriate.) Continue until improvement, not for a predetermined number of sessions. Electrolysis is an accepted permanent hair removal option.
• Medical shaving waivers should be given when indicated to prevent disease exacerbation; arbitrary limits on their duration should be avoided.
• Clinicians should recognize occupational stigma and career effects linked with PFB and shaving waivers.

Six statements did not reach consensus: diagnostic criteria, chemical peel and kojic acid treatments, systemic isotretinoin, hair removal therapy, and shaving with multipleblade razors.

Beyond a Cosmetic Problem

“What I particularly appreciate is that these recommendations recognize that PFB is not simply a matter of using the right shaving cream or finding a better razor,” Friedman told Medscape Medical News. “There is an underlying biological and structural problem. When curved hairs penetrate back into the skin, they trigger a foreign-body inflammatory response-like if it were a splinter. If we continue exposing the skin to the same mechanical insult, we are essentially asking our treatments to put out a fire while someone keeps pouring gasoline on it.”

A few recommendations stand out to Friedman, including the one to leave about 0.5 to 1 mm of hair when using electric clippers. While it may sound counterintuitive, that small amount of hair can make an enormous difference, preventing the shaft from retracting beneath the skin surface.

Laser hair removal addresses the source of the problem, , the follicle producing the offending hair, he said.

The guidelines reinforce what dermatologists know but needed formal guidance on, such as the use of clippers and targeted topicals, said Shari Lipner, MD, PhD, dermatologist at Weill Cornell Medicine and NewYork-Presbyterian Hospital in New York City, who also weighed in on the findings.

However, she added, “open questions remain on shaving frequency, multiblade razors, oral isotretinoin for refractory disease, and superficial peels.” Laser hair removal plays more of a central role in PFB treatment than thought, she said.

The recommendation to support medically indicated shaving waivers without arbitrary expiration dates is crucial, Friedman said. “A chronic disease does not magically disappear because a waiver reaches its expiration date,” he added.

Shaving Waivers, Military Update

In July 2025, a new US Army directive required all soldiers to be clean-shaven while on duty unless they had an approved religious accommodation to keep a beard, and as of July 7, the Army was not issuing any more permanent waivers. Service members can be granted a temporary shaving waiver and will participate in a treatment plan, and unit commanders will initiate separation of service members if a waiver is needed after more than 1 year of medical treatment, according to the directive.

As of October 2026, there is no updated guidance, according to the Pentagon press office.

The press officer could not say exactly how many waivers have been granted, referring Medscape Medical News to the four branches for a count. At press time, none of the branches had responded, but a story published in September in the military publication Task & Purpose estimated that as many as 16,300 may need the medical shaving waivers.

Shaving waivers, even though they can be considered medically necessary as a PFB treatment, have been linked with delays in promotions among Black service members, researchers reported in 2023.

Veterans and PFB: A Closer Look

A week after the recommendations were published, a separate research letter, published in JAMA Dermatology, provided estimates of PFB diagnoses in US veterans. 

Of 23,768 veterans diagnosed with PFB from 2016 to 2022 (93% male), the authors reported that 73.4% identified as Black or African American, 18.4% White, and 8.2% “other.” The mean annual prevalence of the diagnosis was 8.9 (95% CI, 8.8-9.0) per 10,000 Veterans Health Administration (VHA) patients.

The results, they concluded, “can inform evaluation of dermatologist and procedural resource allocation for PFB care across VHA facilities,” and future research should assess “whether current access to laser services meets the clinical needs of veterans with PFB.”

Alomary and several authors of the consensus statement had no disclosures; other authors had disclosures that were outside the submitted work. Lipner and Friedman reported having no relevant disclosures. One author of the research letter on PFB in veterans had disclosures outside the study.