The Impact of Acne Keloidalis Nuchae

Acne keloidalis nuchae (AKN), also known as folliculitis keloidalis or folliculitis keloidalis nuchae, is a chronic inflammatory disorder typically affecting the occipital scalp and nape of the neck. It is important to note that AKN is generally not associated with acne, is not a true keloid, and can also be present beyond the neck. The etiology behind AKN remains elusive, as multiple factors seem to play a role in disease development. However, aberrant inflammatory response caused by follicular injury is key. It is commonly believed that AKN begins with an injury during a close hair cut or with the use of a razor.

Inflammation to the wall of the hair follicle leads to subsequent destruction of the hair follicle and scarring.

How does this diagnosis impact people of color?

AKN most commonly affects Black men, followed by Latinx/Hispanic men. Scarring alopecia in the involved area is common. While these lesions are benign, their cosmetic appearance may have psychosocial impacts, including on quality of life.

What to look for:

The initial presentation involves small, itchy pink, red, or brown papules and pustules around the area that was recently shaved or cut (typically the scalp and neck). Over time, these may enlarge to form nodules with a keloidal appearance with associated scarring hair loss. Secondary bacterial infections may also occur.

Diagnostic pearls:

The diagnosis of AKN is clinical in nature and involves identification of follicular papules, pustules, and scars on the occipital scalp or nape of the neck. A biopsy should be performed on patients suspected of AKN, as the histology is characteristic for the diagnosis.

Differential:

A nonexhaustive differential for AKN includes:

Treatment:

Preventive strategies are an important component of therapy. Patients should be encouraged to avoid frequent haircuts, close shaves, and wearing hats, helmets, and tight shirt collars, all which can contribute to AKN. Treatment is escalated from topical corticosteroids to intralesional corticosteroids based on disease severity and extent. Systemic therapies such as antibiotics or retinoids may also be used. Other treatment modalities include laser therapy, surgical excision, and targeted ultraviolet B phototherapy.

References

Brahe C, Peters K, Meunier N. Acne keloidalis nuchae in the armed forces. Cutis. 2020 May;105(5):223-226. PMID: 32603383.

East-Innis ADC, Stylianou K, Paolino A, Ho JD (2017) Acne keloidalis nuchae: risk factors and associated disorders—a retrospective study. Int J Dermatol 56(8):828–832

Kundu, Roopal V., and Stavonnie Patterson. “Dermatologic conditions in skin of color: part II. Disorders occurring predominately in skin of color.” American family physician 87.12 (2013): 859-865.

Adegbidi H, Atadokpede F, do Ango-Padonou F, Yedomon H (2005) Keloid acne of the neck: epidemiological studies over 10 years. Int J Dermatol 44(Suppl 1):49–50

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