Acne keloidalis nuchae - Hair and Scalp
Alerts and Notices
SynopsisAcne keloidalis nuchae (AKN), or folliculitis keloidalis, is a chronic inflammatory disease in which pustules and keloid-like papules and plaques occur at the nape of the neck, occipital scalp, and sometimes extend up to the vertex scalp. Despite its name, it is generally accepted that the lesion is not associated with acne, is not a true keloid, and can occur beyond the nuchal area.
The presence of keloids at other locations or having a family history of keloids are not features of the disease. The overwhelming majority of patients with AKN are young Black men. AKN has been reported in other racial / ethnic groups, including individuals of Hispanic and Korean descent and White people. Women are rarely affected unless they shave their hair at the nape of the neck. AKN is rare in patients before puberty or after age 50.
The condition is often painful and disfiguring. Inflammation of the hair follicle and fibrosis of the tissue typically result in scarring, including scarring alopecia. The etiology is unclear; many different hypotheses and factors have been proposed. Inflammation is key in the pathogenesis of AKN; however, whether inflammation is a primary or secondary phenomenon is unclear. Earlier literature suggests that AKN was a form of mechanically induced folliculitis, and it is known that AKN is associated with localized mechanical irritation from shirt collars, football or military helmets, or trauma from shaving or haircuts. Despite this association, AKN has been classified as a primary form of inflammatory scarring alopecia.
The strong male predilection suggests that androgens play a role in pathogenesis. It has been discussed in the literature that the kinky, curly nature of Black hair and the tendency of this curvature to lead to penetration of the skin and development of ingrown hairs (which is known to be pathogenic in pseudofolliculitis barbae) could play a role in the pathogenesis. However, histology and dermoscopy have not demonstrated ingrown hairs to be a feature of AKN. There is also no reported association between the occurrence of pseudofolliculitis barbae and AKN.
Another proposed mechanism is aberrant immune reaction to various antigens including cosmetic products, sebum, Demodex, bacterial skin flora, or dermatophytes. One study showed a higher incidence of seborrheic dermatitis in patients with AKN, raising the question of whether dermatophytes could play a role in pathogenesis.
Other factors that have been suggested are obesity and metabolic syndrome, and certain medications.
L73.0 – Acne keloid
49265008 – Folliculitis keloidalis nuchae
Differential Diagnosis & Pitfalls
- Sarcoidosis – Can present with keloid-like papules in this area.
- Tinea capitis (and its complication, a kerion) – A dermatophyte infection commonly seen in children.
- Folliculitis – May affect other hair-bearing areas of the body.
- Dissecting cellulitis of the scalp – Frequently involves the vertex in addition to the occiput.
- Hidradenitis suppurativa – Usually located in axillary, inguinal, or anogenital areas.
- Acne vulgaris – Look for comedones.
- Nevus sebaceus
- Pseudofolliculitis barbae – Usually affects the beard area.
Patient Information for Acne keloidalis nuchae - Hair and Scalp
OverviewAcne keloidalis nuchae, also known as folliculitis keloidalis, is a chronic skin condition characterized by inflamed papules (small, solid bumps), pustules (small, pus-filled bumps), and scars on the back of the neck.
Although it is not related to common acne, acne keloidalis nuchae initially appears as acne-like lesions of inflamed hair follicles on the back of the neck, and without treatment, it can result in small or large keloid-like scars and potentially hair loss in the affected area.
Who’s At RiskAcne keloidalis nuchae can affect any race / ethnicity, but it is most commonly found in young adult Black men or, less commonly, Latino and Asian men. It is very uncommon in women. In addition, acne keloidalis nuchae is very rarely seen in people before puberty or after middle age.
Signs & SymptomsThe most common locations of acne keloidalis nuchae include the:
- Back of the neck (posterior neck).
- Back of the scalp (occipital scalp).
Self-Care GuidelinesIndividuals with acne keloidalis nuchae should focus on avoiding irritation to the area to help prevent the formation of additional lesions, including:
- Washing the area gently with nonirritating cleansers. (Avoid scrubbing.)
- Avoiding wearing headwear (such as sports helmets) and shirt collars that rub against the back of the neck.
- Avoiding closely shaving the back of the scalp and neck.
Although these self-care measures can help, anyone with acne keloidalis nuchae should see a health professional for treatment in order to prevent progression of the condition.
When to Seek Medical CareIf you suspect you have acne keloidalis nuchae, you should seek help from a health professional such as a dermatologist to prevent the possible formation of large scars and permanent hair loss to the involved areas.
TreatmentsTreatment for acne keloidalis nuchae is most effective when started early.
Topical creams, lotions, or gels may include:
- A retinoid cream such as tretinoin (Retin-A), tazarotene (Avage, Tazorac), or adapalene (Differin).
- A prescription-strength steroid or cortisone preparation.
- A topical antibiotic such as clindamycin (Cleocin T).
- Antibiotic pills such as mupirocin (Bactroban, Centany), doxycycline (Doryx, Adoxa), or rifampin (Rifadin).
- A short course of steroids, such as prednisone (Delatsone, Rayos), for severe or advanced cases only.
- Steroid injections directly into the inflamed bumps or scars.
- Surgical removal of single bumps or larger scars.
- Laser therapy / destruction.
- Liquid nitrogen (freezing or cryotherapy).
Acne keloidalis nuchae - Hair and Scalp