Clinical Reference / Therapeutic Strategies / Acne Keloidalis Nuchae

Acne Keloidalis Nuchae


Key Points

  • Primarily affects the nape of the neck, especially in dark-skinned individuals with curly hair.
  • Marked by follicular inflammation, excessive scarring with alopecia.
  • Irreversible alopecia results in the setting of chronic disease.
  • Both medical and surgical treatments, including laser epilation, should be utilized.

Introduction

This disease primarily affects the nape of the neck of dark-skinned individuals with curly hair, primarily black men, and is a form of follicular inflammation with excessive scarring, which represents a keloidal reaction to prior or ongoing folliculitis. Irreversible alopecia will result in the setting of chronic disease. The role of local trauma, particularly bleeding, within areas of folliculitis has been suggested by patient cohort studies. Patients may or may not form hypertrophic scars or keloids at other sites.

The strategy of therapy is to treat active folliculitis, if present, and to reduce hypertrophic hair fragment induced scars. This can be done utilizing medical therapy, primarily topical antimicrobial agents and systemic antibiotics, or through surgical strategies including excision. There may be a role for phototherapy as well as laser epilation of the hair.

Initial Evaluation

Differential Diagnosis

Staphylococcal folliculitis

Furuncle

Herpetic folliculitis

Scleredema (Buschke)

Treatment

First-line therapy: The first-line therapy for acne keloidalis nuchae is medical therapy to treat any existing infection and to reduce inflammation.

First steps

  • If active folliculitis is present, culture the lesions for bacteria and prescribe an oral antibiotic such as tetracycline 500 mg twice daily, doxycycline or minocycline 50-100 mg twice daily. This may require several weeks of therapy to gain control of the inflammation.
  • Local phototherapy (UVB) may be effective to reduce inflammation at the site.
  • To prevent folliculitis, treat topically with benzoyl peroxide gel or wash (5%) applied every day to the affected area.
  • To reduce scar formation, inject intralesional triamcinolone acetonide 5-10 mg per cc to individual hypertrophic lesions at 2- to 4-week intervals.

Subsequent steps

  • If active folliculitis persists, reculture the lesions and choose an alternative antibiotic as indicated by the result of culture and sensitivity.
  • If papules do not regress, increase the strength of the intralesional triamcinolone acetonide to 20 mg per cc initially and then to 40 mg per cc if necessary.
  • It may be necessary to continue topical benzoyl peroxide and/or appropriate antibiotic therapy indefinitely.
  • Patients should avoid greasy hair products that may occlude the skin, resulting in occlusive folliculitis.
  • Neck hair should not be trimmed very close to the skin. Frictional exacerbation, stemming from use of electric clippers or razors, as well as trauma to the skin at this site, may contribute to disease flares. Laser epilation may be a highly effective strategy for eliminating the hair present at the site, likely the inciting cause of the folliculitis.

Surgical therapy

Most persistent or extensive cases are best managed by surgical techniques.

  • Few small papules: Individual lesions may be removed by punch biopsy excision and sutured closed.
  • Large plaques: Larger lesions may be removed by surgical excision. Scalpel or laser surgery may be used. Healing may be by second intention or by primary closure. If the defect is closed primarily, tension should be minimal to prevent a spread scar and keloid formation. A tissue expander may provide adequate tissue for primary closure of large lesions.
  • If surgical removal is performed, intralesional injection of triamcinolone into the scar may be required postoperatively.

Pitfalls

  • Avoid surgical procedures in persons who form keloids at other sites.
  • Discontinuation of the topical benzoyl peroxide and/or oral antibiotics may lead to a reactivation of the folliculitis.

When to refer to a dermatologist

  • When the diagnosis of acne keloidalis nuchae is not clear, or when a distinct cause of alopecia or scalp/neck inflammation is suspected.
  • For cases unresponsive to typical systemic antibiotics.
  • For phototherapy, laser epilation, or other surgical intervention.

Clinical Case

Case 1

  • 22-year-old African-American male
  • No significant past medical history and he takes no medications
  • Review of systems is notable only for discomfort, intermittent bleeding and purulent discharge associated with the rash. He denies a history of prior keloidal scarring, skin infections, or alopecia
  • Presents for management of pustules and scarring on the nape present for several years, now associated with hair loss

Initial evaluation

  • Healthy appearing male
  • Firm keloidal plaque (5×2 cm) on the nape studded with pustules, notable hair loss and dolls’ hair tufting
  • Diagnosis: acne keloidalis nuchae
  • A bacterial culture of a pustule is performed
  • Doxycycline 100 mg b.i.d. and benzoyl peroxide wash 5% is prescribed
  • Follow-up in 3 weeks

Three-week follow-up evaluation

  • The neck eruption shows improvement, with only several active pustules present.
  • The bacterial culture taken at the initial evaluation revealed only normal skin flora, so the doxycycline is discontinued. The benzoyl peroxide wash is continued
  • Follow-up in 4 weeks

Follow-up evaluation

  • The patient reports that he is disturbed by the cosmetic appearance of the neck plaque, so after extensive counseling, he opts to have surgical resection of the plaque. Upon resection, he returns for intermittent intralesional triamcinolone acetonide injections with excellent clinical and cosmetic outcome

References

Alexis A et al (2014). Folliculitis keloidalis nuchae and pseudofolliculitis barbae: are prevention and effective treatment within reach? Derm Clin, 32(2):183-191.

Esmat SM et al (2012). The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae: a pilot study, EJD, 22(5):645-650.

Khumalo NP et al (2011). Folliculitis keloidalis nuchae is associated with the risk for bleeding from haircuts, IJD, 50(10):1212-1216.

Kundu RV, Patterson S (2013). Dermatologic conditions in skin of color: part II. Disorders occurring predominately in skin of color, Am Fam Phys, 87(12):859-865.

Loayza E et al (2015). Acne keloidalis nuchae in Latin American women, IJD, Epub ahead of print.

Okoye GA et al (2014). Improving acne keloidalis nuchae with targeted ultraviolet B treatment: a prospective, randomized, split-scalp comparison study, BJD, 171(5):1156-1163.