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. [22]
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. [15] Topical antimicrobial cleaners/shampoos such as gentle foaming benzoyl peroxide washes or chlorhexidine can help prevent secondary infection. [11] 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. [16]
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. [17]
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. [16] Lesions may also be debulked by shaving or curetting prior to injection with triamcinolone.
In 2014, Okoye et al showed that targeted ultraviolet B (290-320 nm) phototherapy, 3 times weekly for 8 weeks, may improve the clinical appearance of fibrotic papules. [23]
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. [24] 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. [25]
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.
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. [26] 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. [27, 28, 29, 30]
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. [11, 31] 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. [32, 33]
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 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.
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.
-
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.
