Treatment and Current Policies on Pseudofolliculitis Barbae in the US Military
Pseudofolliculitis barbae (PFB), or ingrown hairs, is a common skin condition of the face and neck caused by shaving in predisposed individuals who have naturally curly hair. It uniquely affects a disproportionate number of US service members with African ancestry who must abide by strict uniform grooming standards across the entire military. The main rationale behind this policy is that a beard can prevent a proper seal when using breathing protection devices such as gas masks or N95 respirators. Against the backdrop of the COVID-19 pandemic and ever-looming overseas conflicts, dermatologists who treat service members should be aware of the separate yet related guidelines to treat PFB that each military branch follows. Herein, we review the treatments and current policies on PFB in the US Military.
Practice Points
- Pseudofolliculitis barbae (PFB) is common among US service members due to grooming standards in the military.
- Each military branch follows separate yet related guidelines to treat PFB.
- The best treatment for severe or refractory cases of PFB is a long-term shaving restriction or laser hair removal.
The Navy has outlined the most specific timeline for therapy for PFB. The regulations allow a 60-day temporary shaving chit that expires on the day of the appointment with the dermatologist or PCM. Although sailors were previously mandated to fully grow out their beards without modifications during the 60-day shaving chit period, Navy leadership recently overturned these requirements. However, permanent shaving chits are still not authorized in the Navy.
Service members are trying to destigmatize shaving profiles and facial hair in our military. A Facebook group called DoD Beard Action Initiative has more than 17,000 members and was created in 2021 to compile testimonies and data regarding the effects of PFB on airmen.23 Soldiers also have petitioned for growing beards in the garrison environment with more than 100,000 signatures, citing that North Atlantic Treaty Organization allied nations permit beard growth in their respective ranks.24 A Sikh marine captain recently won a lawsuit against the US Department of the Navy to maintain a beard with a turban in uniform on religious grounds.25
The clean-shaven look remains standard across the military, not only for uniformity of appearance but also for safety concerns. The Naval Safety Center’s ALSAFE report concluded that any facial hair impedes a tight fit of gas masks, which can be lethal in chemical warfare. However, the report did not explore how different hair lengths would affect the seal of gas masks.26 It remains unknown how 0.25 inch of facial hair, the maximum hair length authorized for most PFB patients, affects the seal. Department of Defense occupational health researchers currently are assessing how each specific facial hair length diminishes the effectiveness of gas masks.27
Furthermore, the COVID-19 pandemic has led to frequent N95 respirator wear in the military. It is likely that growing a long beard disrupts the fitting of N95 respirators and could endanger service members, especially in clinical settings. However, one study confirmed that 0.125 inch of facial hair still results in 98% effectiveness in filtering particles for the respirator wearers.28 Although unverified, it is surmisable that 0.25 inch of facial hair will likely not render all respirators useless. However, current Occupational Safety and Health Administration guidelines require fit tests to be conducted only on clean-shaven faces.29 Effectively, service members with facial hair cannot be fit-tested for N95 respirators.
More research is needed to optimize treatment protocols and regulations for PFB in our military. As long as the current grooming standards remain in place, treatment of PFB will be a controversial topic. Guidelines will need to be continuously updated to balance the needs of our service members and to minimize risk to unit safety and mission success. Department of Defense Instruction 6130.03, Volume 1, revised in late 2022, now no longer designates PFB as a condition that disqualifies a candidate from entering service in any military branch.30 The Department of Defense is demonstrating active research and adoption of policies regarding PFB that will benefit our service members.
