Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Acne Keloidalis Nuchae Treatment & Management

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

Medical Care

Treatment of acne keloidalis nuchae (AKN) is difficult, and numerous modalities have been used with varying degrees of success. No single therapy has emerged as definitely first-line.

The first step in management is education, which is key to preventing disease progression. Patients need to be made aware that the condition is exacerbated by short haircuts and close shaving. In addition, tight-fitting collared shirts, athletic head gear, and self-manipulation should be avoided since they may lead to mechanical shearing of the hairs.

Initiating therapy as quickly as possible after the initial appearance of lesions decreases the chance of long-term cosmetic disfigurement.[17] Topical antimicrobial cleaners/shampoos such as gentle foaming benzoyl peroxide washes or chlorhexidine can help prevent secondary infection.[10] Tar shampoos may provide an effective alternative. In addition, mild keratolytic agents containing alpha-hydroxy acids or topical retinoids may help soften the coarse hairs. Patients should discontinue hair greases or pomades, which can interfere with hair growth.[18]

Early, mild papular disease may respond to potent or superpotent topical steroids with or without the use of topical retinoids. This latter combination seems to be somewhat more effective than superpotent topical steroids alone.[19]

When pus or serous drainage is present, a culture should be taken. The use of a topical antibiotic (such as clindamycin) twice-daily may be advantageous to treat any bacterial superinfection. If active folliculitis is present, oral antibiotics such as doxycycline or minocycline should be used for several weeks to gain control over the inflammation. If active folliculitis persists or progresses despite adequate therapy, perform tissue culture and treat accordingly.

Intralesional triamcinolone acetonide injection can be helpful to reduce the size and firmness of papules and nodules. Doses range from 5 mg/mL up to 40 mg/mL for more firm and large lesions. Pretreatment anesthesia with topical lidocaine cream may reduce pain during injection. Alternatively, triamcinolone may be diluted in lidocaine to provide anesthesia with injection. Risks include skin atrophy and hypopigmentation. Liquid nitrogen may be administered to lesions to create edema and ease the injection process.[18]  Lesions may also be debulked by shaving or curetting prior to injection with triamcinolone.

Recently, Okoye et al showed that targeted ultraviolet B (290-320nm) phototherapy, three times weekly for 8 weeks, may improve the clinical appearance of fibrotic papules.[20]

In rare cases in which patients have large, inflamed lesions, a short course of oral corticosteroids may be considered.

Cryotherapy has also proven to be successful as monotherapy in some cases.[21] The area is frozen for 20 seconds, allowed to thaw, and is then frozen again 1 minute later. The process may be painful for patients, and the treated site often becomes hypopigmented because of destruction of the melanocytes and may remain so for up to 12-18 months.

Radiation therapy and intralesional 5-fluorouracil have been reported, but should only be considered for refractory cases.[22]

Once active disease is controlled, maintenance therapy can be used with a combination of topical retinoids, benzoyl peroxide gel or wash, and intermittent use of topical corticosteroids.

Next

Surgical Care

Laser ablation using various lasers (eg, carbon dioxide, 1064-nm Nd:YAG, 810-nm diode) should be considered for lesions refractory to other treatments.[23] One case series showed that 4 monthly laser hair epilation sessions using the diode laser (810 nm) in addition to a topical retinoid and steroid resulted in long-lasting improvement in the appearance and prevention of lesions. Laser hair epilation allows for coagulation necrosis of both viable hair follicles and fragmented hair shafts in the deep dermis.[24, 25]

Stable fibrotic lesions may be anesthetized with lidocaine and removed with punch biopsy or excision. The punch should extend deep into the subcutaneous tissue so that the entire hair follicle is excised. Superficial biopsies tend to have a much higher incidence of recurrence. After excision is performed, the wound edges can be injected with 10-40 mg/mL of triamcinolone acetonide to reduce inflammation. Silk sutures may be used to re-approximate the skin as they cause less of an inflammatory response than nylon sutures. Instruct patients to clean the postoperative area 3 times a day with a mild cleanser, followed by application of a topical antibiotic ointment. The sutures should be removed in 7-10 days, and the patient should then begin a twice-daily topical retinoic acid/corticosteroid regimen for 4-6 weeks.

The preferred method of excision for larger linear lesions (1 cm or less in diameter) is a horizontal ellipse with primary closure; however, excision by carbon dioxide laser and electrosurgery followed by secondary-intention healing are also viable options, especially for lesions that cannot be easily closed primarily.[10, 26]  The excision should extend below the hair follicles, and the area should be reapproximated with 4-0 silk sutures.

Always remember that when closing the area, ensure the patient’s neck is not in a flexed position; otherwise, the patient will spend a week or longer having to look upward.

An important caveat with surgical excision is that primary closure often results in recurrences and/or hypertrophic scarring, and data show that allowing lesions to heal by secondary intention results in fewer recurrences. Wound healing is typically achieved within 6-10 weeks, and, in general, the surgical site contracts to an area smaller and flatter than the original site.[27, 28]

Postoperative care is basically the same as that for punch grafts. Pain medication may be necessary for the first 48 hours.

Have patients return in 24-36 hours (preferably with the person responsible for changing dressings) for removal of the initial dressing. Soak the area with sodium chloride solution to facilitate the removal of the dressing and to clean the postoperative site.

Instruct patients to start cleaning the site twice a day (following the regimen above) once the dressing is removed. Instruct patients to return for follow-up in 1 week, or, sooner, if any complications occur.

Instruct patients to return for follow-up care for possible initiation of intralesional steroid injections or to begin topical steroid/retinoic acid therapy once the area has healed, usually in 2-3 months. Do not begin intralesional steroids prior to complete would healing because this can result in wound dehiscence.

A follicular papule or pustule occasionally develops along the border of the linear scar. Treat all inflammatory lesions with topical clindamycin or chloramphenicol until the infection subsides. The residual papule can then be treated with topical or intralesional steroids or excised via a punch biopsy.

Excision followed by grafting is typically not cosmetically acceptable because it results in a large, depressed, non–hair-bearing area.

Previous
Next

Complications

Keloidlike plaques, scarring alopecia, chronic draining sinuses, and bacterial infection are complications of acne keloidalis nuchae.

Previous
Next

Prevention

Acne keloidalis nuchae (AKN) patients should avoid shaving the posterior part of the hairline close to the skin. Additionally, patients should discontinue wearing clothes or athletic gear that rubs or irritates the posterior parts of the scalp and the neck.

Previous
 
 
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.

References
  1. Dinehart SM, Herzberg AJ, Kerns BJ, Pollack SV. Acne keloidalis: a review. J Dermatol Surg Oncol. 1989 Jun. 15(6):642-7. [Medline].

  2. Gloster HM Jr. The surgical management of extensive cases of acne keloidalis nuchae. Arch Dermatol. 2000 Nov. 136(11):1376-9. [Medline].

  3. Adamson HG. Dermatitis papillaris capillittii (Kaposi). Acne keloid. Br J Dermatol. 1914. 26:69-83.

  4. Knable AL Jr, Hanke CW, Gonin R. Prevalence of acne keloidalis nuchae in football players. J Am Acad Dermatol. 1997 Oct. 37(4):570-4. [Medline].

  5. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol. 2007 Nov. 157(5):981-8. [Medline].

  6. Grunwald MH, Ben-Dor D, Livni E, Halevy S. Acne keloidalis-like lesions on the scalp associated with antiepileptic drugs. Int J Dermatol. 1990 Oct. 29(8):559-61. [Medline].

  7. Wu WY, Otberg N, McElwee KJ, Shapiro J. Diagnosis and management of primary cicatricial alopecia: part II. Skinmed. 2008 Mar-Apr. 7(2):78-83. [Medline].

  8. Sperling LC, Homoky C, Pratt L, Sau P. Acne keloidalis is a form of primary scarring alopecia. Arch Dermatol. 2000 Apr. 136(4):479-84. [Medline].

  9. Herzberg AJ, Dinehart SM, Kerns BJ, Pollack SV. Acne keloidalis. Transverse microscopy, immunohistochemistry, and electron microscopy. Am J Dermatopathol. 1990 Apr. 12(2):109-21. [Medline].

  10. Alexis A, Heath CR, Halder RM. Folliculitis keloidalis nuchae and pseudofolliculitis barbae: are prevention and effective treatment within reach?. Dermatol Clin. 2014 Apr. 32 (2):183-91. [Medline].

  11. Kundu RV, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominately in skin of color. Am Fam Physician. 2013 Jun 15. 87(12):859-65. [Medline].

  12. Kelly AP. Pseudofolliculitis barbae and acne keloidalis nuchae. Dermatol Clin. 2003 Oct. 21(4):645-53. [Medline].

  13. George AO, Akanji AO, Nduka EU, Olasode JB, Odusan O. Clinical, biochemical and morphologic features of acne keloidalis in a black population. Int J Dermatol. 1993 Oct. 32(10):714-6. [Medline].

  14. Goh MS, Magee J, Chong AH. Keratosis follicularis spinulosa decalvans and acne keloidalis nuchae. Australas J Dermatol. 2005 Nov. 46(4):257-60. [Medline].

  15. Janjua SA, Iftikhar N, Pastar Z, Hosler GA. Keratosis follicularis spinulosa decalvans associated with acne keloidalis nuchae and tufted hair folliculitis. Am J Clin Dermatol. 2008. 9(2):137-40. [Medline].

  16. Luz Ramos M, Munoz-Perez MA, Pons A, Ortega M, Camacho F. Acne keloidalis nuchae and tufted hair folliculitis. Dermatology. 1997. 194(1):71-3. [Medline].

  17. Adegbidi H, Atadokpede F, do Ango-Padonou F, Yedomon H. Keloid acne of the neck: epidemiological studies over 10 years. Int J Dermatol. 2005 Oct. 44 Suppl 1:49-50. [Medline].

  18. Quarles FN, Brody H, Badreshia S, et al. Acne keloidalis nuchae. Dermatol Ther. 2007 May-Jun. 20(3):128-32. [Medline].

  19. Kelly AP. Pseudofolliculitis barbae and acne keloidalis nuchae. Dermatol Clin. 2003 Oct. 21 (4):645-53. [Medline].

  20. Okoye GA, Rainer BM, Leung SG, Suh HS, Kim JH, Nelson AM, et al. Improving acne keloidalis nuchae with targeted ultraviolet B treatment: a prospective, randomized, split-scalp comparison study. Br J Dermatol. 2014 Nov. 171 (5):1156-63. [Medline].

  21. Layton AM, Yip J, Cunliffe WJ. A comparison of intralesional triamcinolone and cryosurgery in the treatment of acne keloids. Br J Dermatol. 1994 Apr. 130(4):498-501. [Medline].

  22. Millán-Cayetano JF, Repiso-Jiménez JB, Del Boz J, de Troya-Martín M. Refractory acne keloidalis nuchae treated with radiotherapy. Australas J Dermatol. 2015 Jul 29. [Medline].

  23. Kantor GR, Ratz JL, Wheeland RG. Treatment of acne keloidalis nuchae with carbon dioxide laser. J Am Acad Dermatol. 1986 Feb. 14(2 Pt 1):263-7. [Medline].

  24. Shah GK. Efficacy of diode laser for treating acne keloidalis nuchae. Indian J Dermatol Venereol Leprol. 2005 Jan-Feb. 71(1):31-4. [Medline].

  25. Esmat SM, Abdel Hay RM, Abu Zeid OM, Hosni HN. The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study. Eur J Dermatol. 2012 Sep-Oct. 22(5):645-50. [Medline].

  26. Califano J, Miller S, Frodel J. Treatment of occipital acne keloidalis by excision followed by secondary intention healing. Arch Facial Plast Surg. 1999 Oct-Dec. 1(4):308-11. [Medline].

  27. Glenn MJ, Bennett RG, Kelly AP. Acne keloidalis nuchae: treatment with excision and second-intention healing. J Am Acad Dermatol. 1995 Aug. 33(2 Pt 1):243-6. [Medline].

  28. Bajaj V, Langtry JA. Surgical excision of acne keloidalis nuchae with secondary intention healing. Clin Exp Dermatol. 2008 Jan. 33(1):53-5. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.