Acne Keloidalis Nuchae Workup

  • Author: Philip R Letada, MD; Chief Editor: William D James, MD   more...
 
Updated: Aug 5, 2011
 

Laboratory Studies

Bacterial culture and sensitivity testing of acne keloidalis nuchae (AKN) pustules and draining sinuses should be considered. If pathogenic microorganisms are identified, appropriate antibiotics should be prescribed.

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Procedures

A biopsy may be performed if the clinical presentation is atypical and to exclude other similar conditions.

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Histologic Findings

The histological findings vary depending on the timing of the biopsy. The initial infiltrate is primarily composed of neutrophils and lymphocytes that are distributed around the lower infundibulum and isthmus of the hair follicle. Subsequently, the follicle and sebaceous glands are destroyed, with liberation of the naked hair shafts into the dermis. Acute and granulomatous inflammation surrounds the free hair shafts, and, ultimately, fibrosis ensues. Scarring alopecia ensues in long-standing lesions, marked by dermal fibrosis associated with numerous plasma cells. True keloidal collagen is typically not a feature.

Often, acute and chronic inflammation may be present in the same region, because new lesions often develop adjacent to chronic lesions. Sinus tracks can be identified in long-standing lesions. Intact hair follicles at the margins may exhibit polytrichia, with more than one hair shaft noted in a single follicle, but this is physiologic for the occiput.[14] Individual early papules may also demonstrate ingrown hairs, and these may be seen clinically in patients without progressive scarring alopecia.

A dense plasma cell infiltrate surrounding a hair A dense plasma cell infiltrate surrounding a hair follicle. Naked hair shafts embedded within a fibrotic dermiNaked hair shafts embedded within a fibrotic dermis.
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Contributor Information and Disclosures
Author

Philip R Letada, MD  Resident Physician, Department of Dermatology, Naval Medical Center San Diego

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.

Coauthor(s)

Elizabeth Kline Satter, MD, MPH  Chairman, Department of Dermatology, Naval Medical Center San Diego

Elizabeth Kline Satter, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American Medical Women's Association

Disclosure: Nothing to disclose.

Specialty Editor Board

James W Patterson, MD  Professor of Pathology and Dermatology, Director of Dermatopathology, University of Virginia Medical Center

James W Patterson, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Dermatopathology, Royal Society of Medicine, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

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

Disclosure: Nothing to disclose.

John G Albertini, MD  Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Program Director, ACGME Accredited Fellowship in Procedural Dermatology

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

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

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

Disclosure: Elsevier Royalty Other

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, A. Paul Kelly, MD, to the development and writing of this article.

References

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

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

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

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

 
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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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