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Acne Keloidalis Nuchae Medication

  • Author: Elizabeth K Satter, MD, MPH; Chief Editor: William D James, MD  more...
 
Updated: Feb 11, 2016
 

Medication Summary

The goals of pharmacotherapy are to reduce inflammation and eliminate infection, if present.

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Corticosteroids

Class Summary

These agents are used for their anti-inflammatory properties, but they must be used with caution because they have local and systemic side effects.

Topical corticosteroids may be used alone or in combination retinoic acid.

Triamcinolone (Kenalog-10, Kenalog-40, Aristospan)

 

Triamcinolone can be used topically or injected intralesionally. It decreases inflammation by suppressing the migration of PMN leukocytes and reversing capillary permeability.

Prednisone

 

Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. It is used when the patient has an acute flare.

Clobetasol propionate (Temovate, Clobex, Cormax)

 

Clobetasol propionate is a class 1, superpotent steroid that can be applied to the skin twice daily for 2 weeks. It comes in various formulations as solutions, lotions, creams, ointments, gels, and foams. Clobetasol propionate causes vasoconstriction, inhibits mitotic activity, and stimulates the synthesis of enzymes responsible for decreasing inflammatory reactions.

Halobetasol (Ultravate)

 

Halobetasol inhibits the initial manifestation of the inflammatory process, as well as the subsequent sequelae, which may include angiogenesis and fibroblast proliferation.

Fluocinonide (Vanos)

 

Fluocinonide is a class 2, potent topical steroid. It is available in various formulations, including a solution, cream, and ointment.

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Retinoid-like Agents

Class Summary

Although the exact mechanism of action for AKN is unknown, retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes, modulate keratinocyte differentiation, and have anti-inflammatory properties.

Isotretinoin (Claravis, Amnesteem, Sotret)

 

Isotretinoin is an oral retinoid indicated for recalcitrant, nodulocystic acne. It addresses all four pathogenic factors involved the development of acne: follicular hyperkeratinization, inflammation, sebum production, and P acnes growth. Treatment is weight-based, usually dosed initially 0.5 mg/kg and increased to 1 mg/kg. The total dosage ranges from 120-150 mg/kg and is achieved over 4-6 months. Patients must be registered into the government-regulated iPledge program in order to receive the medication.

Tretinoin topical (Retin-A, Avita, Refissa, Renova, Tretin X, Atralin)

 

Although the exact mechanism of action of tretinoin is unknown, retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes, modulate keratinocyte differentiation, and have anti-inflammatory properties. Tretinoin topical is available as 0.025%, 0.05%, and 0.1% creams and 0.01% and 0.025% gels.

Adapalene (Differin)

 

Adapalene inhibits microcomedo formation. It normalizes keratinocyte differentiation in sebaceous follicles and it has anti-inflammatory properties. Adapalene is available as 0.1% gel, cream, and lotion and 0.3% gel..

Tazarotene (Tazorac)

 

Tazarotene inhibits microcomedo formation. It normalizes keratinocyte differentiation in sebaceous follicles and has anti-inflammatory properties. Tazarotene is available as 0.05% and 0.1 creams and gels.

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Antibiotics, Other

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.

Mupirocin (Bactroban, Centany)

 

Mupirocin is a topical antibiotic; it inhibits bacterial growth by inhibiting RNA and protein synthesis.

Doxycycline (Doryx, Adoxa, Monodox, Vibramycin)

 

Doxycycline is a broad-spectrum antibiotic with excellent gram positive coverage, including most resistant staph organisms. It inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Doxycycline may block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Rifampin (Rifadin)

 

Rifampin inhibits RNA synthesis in bacteria by binding to the beta-subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.

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Acne Agents, Topical

Class Summary

Acne products are used for the treatment of mild to moderate acne vulgaris. These agents may have antibacterial and comedolytic properties. In severe cases, the agents may be used as an adjunct in therapeutic regimens.

Benzoyl peroxide (BenzeFoam, PanOxyl, Triaz, Neutrogena On The Spot, Invisible Acne Treatment, Acne Clear Maximum Strength)

 

Benzoyl peroxide is an oxidizing agent that possesses antibacterial properties and is comedolytic. Benzoyl peroxide is oxidized into benzoic acid with contact to the skin. It is available over the counter and by prescription. It can be used as a topical leave-on or wash-off product.

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Contributor Information and Disclosures
Author

Elizabeth K Satter, MD, MPH Dermatologist and Dermatopathologist

Elizabeth K Satter, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Medical Womens Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; President-Elect, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Received grant/research funds from Genentech for investigator.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Joshua A Zeichner, MD Assistant Professor, Director of Cosmetic and Clinical Research, Mount Sinai School of Medicine; Chief of Dermatology, Institute for Family Health at North General

Joshua A Zeichner, MD is a member of the following medical societies: American Academy of Dermatology, National Psoriasis Foundation

Disclosure: Received consulting fee from Valeant for consulting; Received grant/research funds from Medicis for other; Received consulting fee from Galderma for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Pharmaderm for consulting; Received consulting fee from Onset for consulting.

Acknowledgements

A Paul Kelly, MD Chief, Clinical Professor, Department of Internal Medicine, Division of Dermatology, King/Drew Medical Center, Charles Drew University of Medicine and Science

A Paul Kelly, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, National Medical Association, and Pacific Dermatologic Association

Disclosure: Nothing to disclose.

Philip R Letada, MD Dermatologist, Associates in Dermatology, Hampton, VA

Philip R Letada, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Association of Military Dermatologists

Disclosure: Nothing to disclose.

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Numerous acne keloidalis papules and plaques in a white man with straight hair.
A large acne keloidalis plaque in a bandlike distribution at the posterior occiput in an African American man.
A large acne keloidalis plaque on the occipital region in an African American patient. This man also had perifolliculitis of the scalp and acne conglobata (the follicular occlusion triad).
Numerous papules that have coalesced into a large plaque, within which are tufts of hairs with several hair shafts exiting the same follicular orifice.
A dense plasma cell infiltrate surrounding a hair follicle.
Naked hair shafts embedded within a fibrotic dermis.
 
 
 
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