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Acne Keloidalis Nuchae

Dermatitis Papillaris Capillitii

This disease primarily affects the nape of the neck of black men and is a form of follicular inflammation with excessive scarring which represents a keloidal reaction to prior or ongoing folliculitis. The strategy of therapy is to treat active folliculitis, if present, and to reduce hypertrophic hair fragment induced scars. Patients may or may not form hypertrophic scars or keloids at other sites.

First steps

  1. 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.
  2. To prevent folliculitis, treat topically with benzoyl peroxide gel or wash applied every day to the affected area.
  3. To reduce scar formation, inject intralesional triamcinolone acetonide 5-10 mg per cc to individual hypertrophic lesions at 2- to 4-week intervals.

Ancillary Measures

  1. Patients should avoid greasy hair products.
  2. Neck hair should not be trimmed short.

Next steps

  1. If active folliculitis persists, reculture the lesions and chose an alternative antibiotic as indicated by the result of culture and sensitivity.
  2. If papules do not regress, increase the strength of the intralesional steroid to 20 mg per cc initially and then to 40 mg per cc if necessary.
  3. It may be necessary to continue topical benzoyl peroxide and/or appropriate antibiotic therapy indefinitely.

Surgical Therapy

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

  1. Few small papules: Individual lesions may be shaved off or preferably punched out and sutured closed.
  2. Large plaques: Larger lesions may be removed by surgical excision. Scalpel or laser surgery may be used. Healing may be by secondary 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.
  3. If surgical removal is performed, intralesional injection of triamcinolone into the scar may be required postoperatively.

Pitfalls

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