ArticlePDF Available

Acne Keloidalis Nuchae ( Folliculitis Keloidalis )

Authors:
Basem Abbas Ahmed Al-Ubaidi at Ministry of Health, Kingdom of Bahrain
Basem Abbas Ahmed Al-Ubaidi
Download full-text PDF
Read full-text
Download citation

Abstract

Acne Keloidalis Nuchae (AKN) is characterized by multiple follicular-based papules, pustules, nodules, keloid-like, hypertrophic plaques. AKN typically occurs on the posterior occipital scalp and develops almost exclusively in young, dark-skinned males. Early diagnosis of AKN and proper management would have a good outcome, before progressing to ugly untreatable scarring. A thirty-five-year-old Indian male presented with slightly itching papules with variable pain developed from multiple pimples on the posterior occipital region. The patient was given oral antibiotics (doxycycline) twice daily for four weeks. Thereafter, the patient was given high-potency topical steroids (0.05% clobetasol propionate) twice a day for another two weeks. The large keloidal lesions were treated with cryotherapy for three sessions which resulted in significant lesion regression.
Content uploaded by Basem Abbas Ahmed Al-Ubaidi
Author content
All content in this area was uploaded by Basem Abbas Ahmed Al-Ubaidi on Nov 03, 2016
Content may be subject to copyright.
Bahrain Medical Bulletin, Vol. 37, No. 3, September 2015
Education-Family Physician Corner
Acne Keloidalis Nuchae (Folliculitis Keloidalis)
Basem Al Ubaidi, FMAB, MHPE*
Acne Keloidalis Nuchae (AKN) is characterized by multiple follicular-based papules,
pustules, nodules, keloid-like, hypertrophic plaques. AKN typically occurs on the
posterior occipital scalp and develops almost exclusively in young, dark-skinned males.
Early diagnosis of AKN and proper management would have a good outcome, before
progressing to ugly untreatable scarring.
A thirty-five-year-old Indian male presented with slightly itching papules with variable
pain developed from multiple pimples on the posterior occipital region. The patient was
given oral antibiotics (doxycycline) twice daily for four weeks. Thereafter, the patient
was given high-potency topical steroids (0.05% clobetasol propionate) twice a day for
another two weeks. The large keloidal lesions were treated with cryotherapy for three
sessions which resulted in significant lesion regression.
___________________________________________________________________________
* Consultant Family Physician
Ministry of Health
Kingdom of Bahrain
Email: bahmed1@health.gov.bh
Acne (folliculitis) Keloidalis Nuchae (AKN) is recognized as chronic, fibrotic papules,
nodules and pustules which lead to scarring alopecia at the back of the neck and occiput1. It is
usually seen as asymptomatic, keloidal plaques; however, patients may have burning pain or
stubborn pruritus from either pus or multiple oozing sinuses. It would ultimately affect the
patient’s quality of life (QOL) as the scarring is difficult to treat, and it is sometimes seen in
obvious locations2.
The prevalence of AKN is 0.5%; mostly are seen in the dark-skinned individuals of African
descent or black Asian, with a male-to-female frequency rate of 20:1; ages ranges from 14 to
25 years1,3-5.
AKN is either idiopathic or secondary to a direct reaction to hair growth, wearing helmets or
irritation from long, curly/frizzy hair trapped between shirt collars and a fat neck. The
predisposing factors of AKN are constant irritation from foreign body reaction and advanced
fibrosis with low-grade bacterial infections. The physician should be able to differentiate
AKN from other common skin lesions, such as impetigo, acne vulgaris, tinea capitis,
hidradenitis suppurativa, dissecting cellulitis, pseudopélade of Brocq, keloid, and infectious
folliculitis2. The diagnosis of AKN is usually made clinically while a biopsy is necessary
only in atypical cases. In cases that involve the occurrence of abscesses or pustules, it is
necessary to have it drained and sent for culture and sensitivity3,6.
The aim of this presentation is to report a rare case of AKN in a young patient who had
successful outcome after medical treatment.
THE CASE
A thirty-five-year-old Indian male presented with lesions initially manifested as slightly
itching papules with variable pain developed from multiple pimples on the posterior occipital
region. It grew over six months and had become disfiguring, painful and keloid-like plaques.
The patient revealed history of close shaving and chronic rubbing of the area by clothing.
On examination, it was observed that multiple lesions had developed in hair-bearing areas of
the skin. The lesions were firm, dome-shaped, follicular-based papules, pustules and plaques
measuring between 4-5 mm in diameter. Keloid-like papules had merged to form cluster
shape on the posterior of the neck which reached more than 10 cm in diameter. Loss of hair
and damaged hair shafts had been seen within and at boundaries of the plaques with purulent
discharge and traumatized lesions when the hair was groomed, see figure 1.
Figure 1: Multiple Papular, Pustular, and Keloid-Like Lesions on the Posterior
Occipital Region
The patient was given oral antibiotics (doxycycline) twice daily for four weeks. Thereafter,
the patient was given high-potency topical steroids (0.05% clobetasol propionate) twice a day
for another two weeks. The large keloidal lesions were treated with cryotherapy for three
sessions which resulted in significant lesion regression.
DISCUSSION
Treatment of AKN is challenging and difficult as the lesions often are intractable. Patients
might present with history of numerous modalities of previous treatment with varying
degrees of success. Early diagnosis and timely treatment of AKN reduces the possibility of
long-term keloidal scarring and disfigurements2.
Our primary goal of treatment was focused on the patient’s education. He was advised to
discontinue wearing possible offending garments that may cause irritation, such as tight
fitting shirts and to instruct his barbers not to shave the posterior part of his hairline. The
patient should avoid hair greases or pomades which could interfere with hair growth. Hair in
the affected area should be kept long to avoid regrowth into the scalp. The patient is advised
to shampoo with gentle foam washes, such as benzoyl peroxide chlorhexidine or mild
keratolytic agents3.
Treatment of AKN is dependent on the lesion type and disease stage; the treatment could be
medical or surgical. The medical could be oral antibiotics and high-potency topical
steroids2,4. Cryotherapy could be used for large keloidal lesions7.
Patients presented with large abscesses, or oozing sinuses should be drained, culture and
sensitivity should be requested and oral antibiotics and oral prednisolone for 7-10 days
duration should be initiated2.
In advanced, intractable AKN, laser ablation (carbon dioxide laser), intralesional
triamcinolone acetonide, 5-fluorouracil or immunotherapy injection (5 to 40 mg/mL) should
be considered8. Surgical excision of the keloidal-scarring plaque includes a horizontal ellipse
with primary closure9,10.
CONCLUSION
AKN is a chronic, folliculitis disease affect mostly adolescent to adult, dark-skinned
males on the nape of the neck or occipital area. An untreated AKN case ultimately
leads to disfigurement, hypertrophic scarring, chronic abscesses and hair loss.
___________________________________________________________________________
Potential Conflicts of interest: None.
Competing interest: None. Sponsorship: None.
Submission date: 21 May 2014. Acceptance date: 22 July 2015.
Ethical Approval: Approved by North Muharraq Health Center, MOH, Bahrain.
REFERENCES
1. Quarles FN, Brody H, Badreshia S, et al. Acne Keloidalis Nuchae. Dermatol Ther
2007; 20(3):128-32.
2. Adegbidi H, Atadokpede F, do Ango-Padonou F, et al. Keloid Acne of the Neck:
Epidemiological Studies over 10 Years. Int J Dermatol 2005; 44 Suppl 1:49-50.
3. Kelly AP. Pseudofolliculitis Barbae and Acne Keloidalis Nuchae. Dermatol Clin
2003; 21(4):645-53.
4. Khumalo NP, Jessop S, Gumedze F, et al. Hairdressing and the Prevalence of Scalp
Disease in African Adults. Br J Dermatol 2007; 157(5):981-8.
5. Kundu RV, Patterson S. Dermatologic Conditions in Skin of Color: Part II. Disorders
Occurring Predominately in Skin of Color. Am Fam Physician 2013; 87(12):859-65.
6. Cole C, Gazewood J. Diagnosis and Treatment of Impetigo. Am Fam Physician 2007;
75(6):859-64.
7. Acne Keloidalis Nuchae. Therapeutic Strategies in Dermatology. Available at:
http://www.derm101.com/therapeutic/acne-keloidalis-nuchae. Accessed on 2.4.2014.
8. Esmat SM, Abdel Hay RM, Abu Zeid OM, et al. The Efficacy of Laser-Assisted Hair
Removal in the Treatment of Acne Keloidalis Nuchae; a Pilot Study. Eur J Dermatol
2012; 22(5):645-50.
9. Bajaj V, Langtry JA. Surgical Excision of Acne Keloidalis Nuchae with Secondary
Intention Healing. Clin Exp Dermatol 2008; 33(1):53-5.
10. Wu WY, Otberg N, McElwee KJ, et al. Diagnosis and Management of Primary
Cicatricial Alopecia: Part II. Skinmed 2008; 7(2):78-83.
ResearchGate has not been able to resolve any citations for this publication.
Diagnosis and treatment of impetigo
Article
Full-text available
  • Apr 2007
  • AM FAM PHYSICIAN
Impetigo is a highly contagious, superficial skin infection that most commonly affects children two to five years of age. The two types of impetigo are nonbullous impetigo (i.e., impetigo contagiosa) and bullous impetigo. The diagnosis usually is made clinically, but rarely a culture may be useful. Although impetigo usually heals spontaneously within two weeks without scarring, treatment helps relieve the discomfort, improve cosmetic appearance, and prevent the spread of an organism that may cause other illnesses (e.g., glomerulonephritis). There is no standard treatment for impetigo, and many options are available. The topical antibiotics mupirocin and fusidic acid are effective and may be superior to oral antibiotics. Oral antibiotics should be considered for patients with extensive disease. Oral penicillin V is seldom effective; otherwise there is no clear preference among antistaphylococcal penicillins, amoxicillin/clavulanate, cephalosporins, and macrolides, although resistance rates to erythromycin are rising. Topical disinfectants are not useful in the treatment of impetigo.
View
Dermatologic Conditions in Skin of Color: Part II. Disorders Occurring Predominantly in Skin of Color
Article
  • Jun 2013
Several skin conditions are more common in persons with skin of color, including dermatosis papulosa nigra, pseudofolliculitis barbae, acne keloidalis nuchae, and keloids. Dermatosis papulosa nigra is a common benign condition characterized by skin lesions that do not require treatment, although several options are available for removal to address cosmetic concerns. Pseudofolliculitis barbae occurs as a result of hair removal. Altering shaving techniques helps prevent lesions from recurring. In acne keloidalis nuchae, keloidal lesions are found on the occipital scalp and posterior neck. Early treatment with steroids, antibiotics, and retinoids prevents progression. A key part of the management of keloids is prevention. First-line medical therapy includes intralesional steroid injections. The distinct structure of the hair follicle in blacks results in hair care practices that can lead to common scalp disorders. For example, chemical relaxers decrease the strength of hair and may cause breakage. Better patient education, with early diagnosis and treatment, often leads to better outcomes.
View
The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study
Article
  • Sep 2012
  • EUR J DERMATOL
Background: Laser-assisted hair removal causes miniaturization of hair shafts which are the principal contributors to inflammation in acne keloidalis nuchae (AKN). Objective: To assess the efficacy of hair reduction by long pulsed Nd-YAG laser as a therapeutic modality for AKN. Methods: This interventional pilot trial included 16 patients with AKN who received 5 sessions of long pulsed Nd-YAG laser. Lesions were objectively and subjectively assessed at the third and fifth laser sessions, and 1 year after. Global response to treatment was rated using a quartile grading scale regarding the percentage improvement in the count of papules and the size of the plaques. Biopsies were taken before and 2 weeks after the fifth session to evaluate the pathological changes associated with improvement of the treated lesions. Results: All patients showed a significant improvement. The percentage of improvement in the early caseswas significantly higher when compared to late cases.Two weeks after the fifth session, all biopsies showed a significant decrease in the inflammatory infiltrate except one case. Sclerosis was markedly decreased. Complete absence of hair follicles and adenexawas observed, apart from in 2 cases. Conclusion: Laser hair depilation can significantly improve this disfiguring chronic disorder. Starting treatment as early as possible achieves the best results and can stop the disease process if followed by maintenance sessions.
View
Pseudofolliculitis barbae and acne keloidais nuchae
Article
  • Nov 2003
  • DERMATOL CLIN
Pseudofolliculitis barbae is essentially a disorder of the beard in black men who shave. The only permanent cures are beard growth and depilation. An important part of the therapeutic regimen is patient education. Acne keloidalis nuchae refers to the occurrence of keloidal-like papules and plaques on the occipital scalp and posterior neck, almost exclusively in black men. It usually starts after puberty as an acute folliculitis and perifolliculitis, which becomes chronic. As the disease progresses the papules enlarge and some form keloidal-like plaques. There is therapeutic and help and hope for acne keloidalis nuchae patients using the excision and second-intention healing technique plus some of the recently reported laser techniques.
View
Keloid acne of the neck: Epidemiological studies over 10 years
Article
  • Nov 2005
  • INT J DERMATOL
Background Acne keloidalis nuchae is a chronic condition affecting young adult males of African origin. The frequency of the condition is low but its occurrence has a significant impact on the patient's quality of life. Patients and methods We performed a retrospective study on data collected over a period of 10 years in the Department of Dermatology and Venereology at the Centre National Hospitalier et Universitaire (CNHU) in Cotonou, Benin. We examined 90 files covering the period from 1993 to 2002 in terms of the epidemiologic, clinical and therapeutic features and course of the disease. Results The frequency of acne keloidalis nuchae in patients attending the department for consultations over this period was 0.7%. All patients were male, and their mean age was 29 years. The mean period between disease onset and initial consultation in the department was 29 months. Of the patients diagnosed, 82.22% were seen at the stage when the keloid lesions were small. Lesion size did not appear to depend on the duration of the disease. The mean duration of follow up for the 34 patients reviewed was 22 weeks. In nine cases the lesions had spread and in five cases they had resolved. The treatment proposed depended on the type of lesion, but no effective therapeutic guidelines exist. Conclusions The study has demonstrated that, once the clinical stage of purely inflammatory lesions has passed, delay in consultation has a negligible effect on the course of the disease, which remains chronic and recurrent. A preventive approach using Information Education Communication (IEC) would be preferable.
View
Hairdressing and the prevalence of scalp disease in African adults
Article
  • Nov 2007
Anecdotal reports suggest that certain scalp disorders are common in Africans and may be associated with hairstyles. This study of 874 African adults in Cape Town was performed to test this hypothesis. A questionnaire was administered and scalp examinations performed, after ethics approval. Participants included 30.9% men and 69.1% women (median age 36.1 years, range 18-99). Most men had natural hair: 91.7% vs. 24.3% women. The majority of men had recent haircuts (< 4 weeks): 74.8% vs. 9.9% women. The overall prevalence of acne (folliculitis) keloidalis nuchae (AKN) was 3.5%: higher in men than women (10.5% vs. 0.3%). AKN prevalence was not associated with whether clippers or blades were used. However, it was associated with haircut symptoms. Haircut-associated symptoms, i.e. at least one episode of transient pimples (or crusts) and bleeding (however small) were reported in 37% and 18.9% of men, respectively. The latter may have implications for disease transmission. Most women (58.7%) had chemically treated hair (49.2% relaxed and 9.6% permed hair) vs. 2.3% men. The prevalences of traction alopecia (TA) and central centrifugal cicatricial alopecia (CCCA) were 22.6% and 1.9%: higher in women (31.7% vs. 2.2% and 2.7% vs. 0%, respectively). CCCA was highest in women > 50 years (6.7% vs. 1.2%). TA prevalence was highest if the usual hairstyle was extensions attached to relaxed hair (48%). We found associations between specific scalp diseases, hairstyles, gender, and age. These associations need further study, better to elucidate determinants and to improve disease prevention and treatment.
View
Acne keloidalis nuchae
Article
  • May 2007
Our experts feel that the first step in treating patients with acne keloidalis nuchae is explaining that the disease was not caused by the barber using unclean clippers to cut their hair. Patients should be instructed to substitute tight, high-collared shirts with soft or no collared shirts whenever possible. Short haircuts and close scalp shaving should be avoided. Daily shampooing with gently foaming benzoyl peroxide washes, chlorhexidine, or mild keratolytic cleansers containing alpha hydroxy acids or tar are effective alternatives to standard shampoo products. Discontinuance of hair greases and hair pomades is advised. Early, mild papular disease responds to potent or super-potent topical steroids. Larger inflamed papulopustular lesions should be cultured and treated with topical antibiotics (after culture), monthly intralesional triamcinolone (3-10 mg/cc) and an oral antibiotic such as a tetracycline or a tetracycline-derivative minocycline, erythromycin, trimethoprim sulfamethoxazole, or rifampin. Isotretinoin can be considered for rapidly progressing disease. Less keloidal nodules and plaques can be shaved, followed by intralesional triamcinolone injections, injected with triamcinolone and 5FU for three consecutive months, followed by serial excisions and postoperative radiation and/or immunotherapy or injected with 20 mg/cc triamcinolone. When surgery remains the only option, carbon dioxide laser debulkment and excision into the fat, tangential shaving or primary excision with secondary intention healing followed by radiation therapy are alternatives. If primary closure is planned, preoperative assessment of nuchal laxity is beneficial in determining whether serial excisions are indicated. All of our experts agree that obtaining a culture is the first step in treating a patient with dissecting cellulitis of the scalp, although bacterial growth may be the result of rupture and secondary infection. Culture and aspiration can be completed simultaneously by using a 21-gauge needle connected to a vacutainer and red-top tube. Following aspiration, intralesional triamcinolone 10-40 mg/cc is administered in addition to oral antibiotics - trimethoprim, tetracycline, minocycline, or rifampin - is prescribed. Oral prednisone (60 mg tapered over 10 days) helps with the severe inflammation. Once the active disease is controlled, oral zinc gluconate or sulfate 220 mg/day should be considered. Excision and diode and Nd:YAG laser may can used is the lesions are fibrotic. The mainstay of therapy for folliculitis decalvans includes: antiseptic and steroid shampoos, intralesional and oral steroids, and oral antibiotics. Isotretinoin may be beneficial.
View
Surgical excision of acne keloidis nuchae and secondary intention healing
Article
  • Feb 2008
Acne keloidalis nuchae (AKN) is a chronic scarring folliculitis that presents clinically as follicular papules and pustules. These can coalesce into firm hypertrophic plaques and nodules on the nape of the neck, most commonly affecting young adult men. Treatment includes topical steroids/antibiotics and oral antibiotics, but often has disappointing results. Surgical approaches include excision with primary closure or skin grafting, and hair-removal lasers. Another surgical approach is excision with secondary intention healing. This can result in good cosmesis with little or no recurrence. We report two men with AKN where treatment by excision with secondary intention was successful.
View
Diagnosis and Management of Primary Cicatricial Alopecia: Part II
Article
  • Mar 2008
The second part of this 2-part article reviews clinical features, histology, management, and treatment of neutrophilic primary cicatricial alopecias (folliculitis decalvans and dissecting folliculitis) and mixed primary cicatricial alopecias (acne keloidalis, acne necrotica, and erosive pustular dermatosis).
View
Therapeutic Strategies in Dermatology
  • Jan 2014
  • Acne Keloidalis Nuchae
Acne Keloidalis Nuchae. Therapeutic Strategies in Dermatology. Available at: http://www.derm101.com/therapeutic/acne-keloidalis-nuchae. Accessed on 2.4.2014.