Mariusz J. A. Sapijaszko, MD, FRCPC, FAACS, FAAD
Division of Dermatology, Department of Medicine, University of Alberta, AB, Canada
For decades, skin care has primarily been considered to be the domain of women, but recently, an increasing number of men are also endeavouring to maintain optimal skin health and prevent unwanted changes that can occur with intrinsic and extrinsic aging. Caring for the skin requires a basic understanding of its functions and the differences between genders, as well as variations among individuals. Although some skin care products can be effectively used by both men and women, awareness of gender-specific attributes are helpful for guiding aspects of skin care regimens and the choice of products, in order to improve outcomes. This article will focus on the unique facets of men’s skin physiology with particular emphasis on shaving and the treatment of pseudofolliculitis barbae.
Overview of Differences in Men
The skin provides the interface between the body’s internal and external environments. As the largest organ in the body, its complex functions include temperature regulation, biochemical and immune defence against microorganisms, buffering and protection of internal organs, as well as sensation (in relation to physical and social interactions). Among other factors, the skin of men and women differs as a consequence of hormonal influences. Herein, some male-specific physiologic features (Table 1) related to skin are described.
Although hair does not perform a vital function, its importance in self-perception and social interactions is considerable. All hair follicles form before birth and later respond to hormonal influences.
- Hair distribution and characteristics differ between genders and are largely determined by a combination of genetic, cultural, interpersonal, and behavioural factors.
- During adolescence, under the influence of sex hormones (e.g., testosterone), vellus hairs of androgen-sensitive areas (facial, pubic, and axillary regions) mature to terminal hair follicles.
- In addition to stimulating hair growth, the rise in testosterone levels in males increases the size, growth rate, and pigmentation of hair. As such, men have more facial hair than women, making this attribute one of the most defining features of males.1
Sebaceous glands (SGs) are associated with hair follicles throughout the body, with the face and scalp having the highest density. Oily secretions (sebum) from SGs are thought to influence stratum corneum hydration and lubrication, as well as provide protection from microorganisms.
- SGs are regulated by androgens, resulting in increased size and secretory activity.
- Typically, men produce more sebum than women, therefore, severe acne and subsequent potential sequela of acne scarring are more prevalent in men than in women.1,2
Skin thickness reflects the composition of epidermis and dermis; collagen, ground substance, water, and elastic fibers contribute to skin thickness.
- At all ages, male skin is thicker than that of females in all anatomic areas, but onset of skin thinning can occur as early as 20 years of age.1-3
- In contrast, women’s skin, although thinner, maintains its thickness until about the fourth or fifth decades
- of life.
Sweat, an odourless liquid, is produced by eccrine and apocrine glands. Eccrine glands are distributed throughout the body except at the mucous membranes. Apocrine glands are localized in the axillae, areolae, and in the perineal regions.
- Men have a higher sweat rate than women.1
- In comparison with men, sweating is triggered at higher body temperatures before perspiration occurs in women.
- Consistently warm conditions, especially in the underarm regions, encourage bacterial growth that causes body odours. Particularly in males, increased hair density in these areas helps to control moisture. The regimented use of antiperspirants or deodorants can also assist in reducing and managing perspiration and/or odours.
Based on intricate processes, testosterone generally inhibits the immune system, whereas estrogen stimulates it.
- Men have a greater predisposition to bacterial and viral infections, and therefore, recovery from internal infections may present more challenges.1,3
Animal studies indicate that male rat fetuses experience slower rates of epidermal barrier formation in comparison with females. Improved cutaneous wound healing was observed when male mice were castrated, decreasing the influence of androgens.
- At all ages, men appear to have slower wound healing rates than women1,3 and are at greater risk for dysregulated wound healing, which is particularly evident in the elderly population.
Men may have greater susceptibility to skin cancer. More specifically, squamous cell carcinoma and basal cell carcinoma are more commonly diagnosed in males.1,3 In addition, men have higher mortality rates from melanoma, when compared with women.
- Behavioural aspects of men’s lives, as well as gender distinctions in immunity, may explain these differences.
- Consequently, the need for adequate sun protective strategies and annual skin check-ups should be reinforced across all at-risk patient populations.
Facial hair removal practices adopted by men and women can differ significantly. Women prefer manual razors, waxing, threading, electrolysis, or the use of depilatories; whereas men favour the use of manual or electric razors to manage facial hair growth.4 The shaving ritual is individualistic and focused on easing the associated discomfort. As such, the goal of shaving products should be to improve the process by increasing the closeness of the shave and avoid causing redness, dryness, and ingrown hairs. The optimal shave should be fast, comfortable (minimizing irritation, nick/cuts, and razor burns), effective (e.g., achieving desired results and restoring smoother skin post-shave with moisturizers), and safe (e.g., without aggravating or causing more skin problems, such as redness, infection, and ingrown hairs).
The key components of successful shaving include:
In this phase, the hair and skin need to be prepared for shaving. It is important to cleanse the face of pollutants, dirt, and contaminants by using lukewarm water and mild soap. This is followed by application of shaving lubricant (e.g., creams or gels). This step serves to moisten the skin and hairs, making them softer and easier to cut; a dry razor shave is difficult to achieve without aggravating the skin and causing razor burn. Although adequate hydration time allows for easy hair cutting, excess hydration can weaken the skin, making it more vulnerable to damage (i.e., insufficient hydration will leave hair too rigid and excessive hydration will leave skin too soft to withstand contact with the blade). Furthermore, shaving lubricants assist in reducing friction between the skin and the shaving blade, allowing for an easier glide of strokes. The shaving preparation should not aggravate the skin or cause undesirable effects, such as worsening of acne or induce an allergic reaction. Other properties, such as a mild anesthetic effect (minimizing pain and razor burn), scent, as well as texture, may enhance product appeal.
The many different blade-shaving technologies include single- and multiple-blade systems, which are further diversified by manual or electric operation. The basic design premise of multi-blade systems is that it produces a smoother shave in fewer strokes. Less passes improves shaving efficiency and causes less trauma to softened skin. These devices should also allow for full facial as well as neck shaving, while maintaining flexibility in order to access hard-to-reach areas, such as the cleft chin, corners of the mouth, and the region under the nose. The blades should meet quality standards, as imperfections in the free edge can damage skin and even cause scarring. Disposable razors or blade cartridges should be frequently inspected and replaced regularly depending on frequency of use to minimize the chance for cuts, irritation, and infection.
Once the actual shaving is completed, it is essential to restore hydration to just-shaved areas. During the shaving process, the outermost layer of the skin can be removed with the razor blade, resulting in decreased barrier function as well as micro-trauma to the skin, causing dryness and irritation. Moisturization and protection may be restored through the use of non-irritating, emollient enriched aftershave products that do not leave a greasy feel.
Pseudofolliculitis barbae (PFB) (razor bumps) is a common chronic inflammatory, non-infectious condition affecting both men and women; a male preponderance is seen in individuals with coarse or curly hair who shave. PFB frequently results from the habitual removal of unwanted hair, which promotes hairs to enter the dermis or epidermis prior to exiting the follicular opening (trans-follicular penetration) or re-entering skin that is adjacent to the follicular opening (extra-follicular penetration).5,6 The use of inappropriate shaving techniques or devices that tug and pull at the skin), such as a dry and/or close shave (e.g., when pulling the skin taut) can promote trans-follicular penetration. Dry shaves create sharper hair tips and when a close shave is achieved, hair retracts into the follicle, creating conditions for penetration of the follicular wall by the regrown hair. Adequate pre-shave preparation and post-shave use of hydrating emollients can contribute to skin barrier maintenance and reduce the incidence of PFB.
The treatment of PFB should be centered on several key aspects:
Patients need to be well informed as to the causes of PFB with respect to unwanted hair removal and shaving practices.
It is essential to minimize trans-follicular penetration and extra-follicular penetration. As such, the hair should be left extended slightly (0.5mm to 1mm) above the follicular opening. Initially, growing a full beard is advisable to decrease the acute inflammation that is present during the active phase of PFB. Subsequently, shave hairs with the aid of a spacer (protects up to 1mm of hair from being cut), then the use of chemical depilatories or laser hair removal may be advisable.4,7
Reinforce the message to patients that the benefits from following a balanced, healthy lifestyle outweigh the pursuit of managing physical imperfections.
The desired improvement can only be achieved with persistence and focus on avoiding aggravating factors. Over time, repetitive skin trauma can cause papules and pustules to form, further progressing to keloid scars that appear as hard hyperpigmented bumps. The persistent pattern of hair removal practices, as well as patient dissatisfaction with their appearance, can lead to substantial psychosocial distress.
As more manufactures are responding to the growing demand for men’s skin care products and services, it is helpful for clinicians to be aware of the unique properties of male skin physiology, especially when patients seek advice prior to the implementation of therapeutic and cosmetic approaches. In particular, facial skin differs greatly between genders. In contemporary culture, shaving has evolved into a common, often necessary, ritual. With that in mind, acquiring a basic understanding of the complexities of men’s skin better positions physicians to encourage patients to adopt optimal grooming strategies for shaving and skin care in order to avoid inflicting skin damage that can cause other complications, such as pseudofolliculitis barbae, allergenicity, hyperpigmentation, or even permanent scarring.
- Giacomoni PU, et al. Gender-linked differences in human skin. J Dermatol Sci 55(3):144-9 (2009 Sep).
- Tur E. Physiology of the skin – differences between women and men. Dermatol Clin 15(1):5-16 (1997 Jan-Feb).
- Dao H Jr, et al. Gender differences in skin: a review of the literature. Gend Med 4(4):308-28 (2007 Dec).
- Klein AW, et al. Depilatory and shaving products. Clin Dermatol 6(3):68-70 (1988 Jul-Sep).
- Halder RM. Pseudofolliculitis barbae and related disorders. Dermatol Clin 6(3):407-12 (1988 Jul).
- Crutchfield III CE. The causes and treatment of pseudofolliculitis barbae. Cutis 61(6):351-6 (1998 Jun).
- Bridgeman-Shah S. The medical and surgical therapy of pseudofolliculitis barbae. Dermatol Ther 17(2):158-63 (2004).