Chapter 42: Acne Keloidalis Nuchae

SUMMARY

• Acne keloidalis nuchae (AKN) is a chronic scarring folliculitis, more frequently described in young men, with higher phototypes.

• The disease can start with local itching, but what leads the patient to seek medical care are painful inflammatory lesions and stigmatizing chronic keloidiform lesions.

• Treatment includes guidance to avoid triggering trauma and prescription of shampoos, retinoids, and keratolytics for maintenance. Often, the combination of topical, infiltrative and oral corticosteroids, and antibiotics may be necessary. Severe cases usually require surgery, with local excision of the lesions, laser, and radiotherapy.

TIPS FOR DIAGNOSIS

• The initial lesions are pustules and small erythematous papules on the nape of the neck, mainly in black men.

• In trichoscopy, lesions resemble those of folliculitis decalvans (FD), with pustules and perifollicular desquamation. However, unlike FD, small tufts are more frequent than large tufts, and are often found within the keloidiform papules.

TIPS FOR TREATMENT

• Avoid traumas such as short and frequent haircuts, high collars, hats, helmets, or necklaces that traumatize the nape of the neck and occipital area.

• In the early stages, the association of corticosteroids with topical antibiotics, retinoids, and mild keratolytics are sufficient for treatment.

• In chronic phases, the association of topical therapies with intralesional corticosteroids, laser epilation of inflamed residual hair, or surgical excision may be necessary.

DON’T FORGET

• Patient education is the key to treatment, especially regarding haircuts.

• Start treatment as soon as possible, so keloid lesions—characteristic of the disease—do not form.

• Surgery is not curative. In most cases, recurrences are frequent, so surgery should only be considered in extensive, refractory, or very symptomatic cases.

PITFALLS AND CAUTIONS

• The name AKN does not fully reflect the etiopathogenesis of the disease. As it does not occur secondary to acne vulgaris, it is not histologically compatible with keloids and is not restricted to the location of the nape of the neck.

• The association with true keloids in another region of the body is uncommon. When it happens, it seems to be because the two diseases are more frequent in African descendants.

EXPERT PEARLS

• An active search for the disease is necessary, especially in more predisposed individuals as young, Black, and overweight men, because initial lesions are discreet, asymptomatic, and are not seen by the patient as they are on the neck.

• It is part of the treatment to advise on weight loss, not only because there is evidence relating AKN to insulin resistance, but also because obesity and redundancy in the neck cause local trauma, leading to refractory lesions and frequent flare-ups.

PATIENT EDUCATION POINTS

• As local trauma is an important trigger for this chronic condition, patients should be advised about risk factors such as the use of wooden or iron combs, necklaces, caps, and helmets. Obese individuals may benefit from weight loss as redundant skin at the nape creates folds wherein the lesions may develop.

• The disease does ...