What’s Causing This Man’s Folliculitis Barbae?

From the existing literature reports on herpes barbae, it is clear that clues in a patient’s history can aid in making the proper diagnosis. Between 1972 and 2004, 8 cases of herpetic folliculitis on the face in immunocompetent men have been reported, many of which shared similarities to the patient’s case described here (Table 2).^5,7,9-12 No cases have been reported in this patient population in the English literature since 2004. The ages of the men in the reported cases ranged from 21 to 47 years. Five patients initially had been treated with antibiotics for what had been initially diagnosed as a bacterial infection before presenting for follow-up after symptoms did not improve. Six of the 8 patients reported symptoms after shaving, often noting a burning sensation while shaving over the area before the appearance of the rash. Three men had a personal history of herpes labialis without any outbreaks at the time of the presentation, and 2 had been recently exposed to a partner with an active herpes labialis infection. All 8 patients had presented similarly with a follicular or vesiculopustular rash on the face, and 5 were reported to have cervical lymphadenopathy. In most cases, symptoms lasted between 1.5 and 3 weeks and resolved with antiviral treatment, but the dose and duration varied among cases. Interestingly, the first cases reported by Izumi et al in 1972 had been diagnosed correctly initially, but given that acyclovir was not available until 1982,¹³ antibiotics and corticosteroids were used as a treatment without improvement of symptoms.⁷

As in our patient’s case, a known history of herpes infection may not be evident. Viral shedding of HSV often occurs without clinical symptoms and can still occur for a few days after vesicles appear during the crusting stage, if a lesion appears at all.^14,15 Furthermore, herpes folliculitis has been reported to present without surface epithelial changes, making occult herpes infections another diagnostic challenge.¹⁶

Herpes barbae should be considered as a possible diagnosis in patients whose symptoms are not responding to antifungal or antibacterial treatment for the infections of their beard area, especially when considering relevant history, such as history of herpes labialis, shaving history, and recent exposure to herpes labialis. Herpes barbae is often thought to be a disease seen in immunocompromised patients such as those with eczema or HIV but can occur in immunocompetent patients, as well. PCR assay of a sample of the affected areas allows for accurate determination of the causal pathogen, whether viral, fungal, or bacterial.¹⁷ If a high suspicion exists for HSV infection, and PCR results are negative for HSV, it may be worth checking HSV antibodies, especially in cases with no known history of HSV infection.

No clinical trials have been done to recommend the standard treatment for herpes barbae, although it is likely that the treatment for herpes gingivostomatitis, as reported in the cases above, would be sufficient. The patient in this case would have likely experienced spontaneous resolution of his symptoms given that he started antiviral treatment later in the course of his illness, so it is not clear whether the acyclovir he began taking improved the outcome.

Given that a major risk factor for herpes barbae is close shaving with a razor in the presence of an acute orolabial infection,¹⁸ it is imperative to educate patients on shaving practices in order to avoid irritation or trauma of the hair follicle, especially in men with a history of herpes infections of the mouth or face. As noted in this case, it would be best to recommend that patients avoid using old razors in order to not only reduce skin trauma, but also reduce the possibility of autoinoculation and spreading, since the razor can also serve as a fomite.^19,20

REFERENCES:

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