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Chapter 84: Acne Keloidalis Nuchae

Donald A. Glass; Ariel Knowles

ACNE KELOIDALIS NUCHAE

Therapeutic Approach

Acne keloidalis nuchae (AKN) is actually a misnomer—as it is not induced by acne, not histologically consistent with keloids and is not limited to the posterior neck. More accurately termed “folliculitis keloidalis,” it is a chronic inflammatory follicular disorder, primarily affecting Black men, which presents with persistent papules and, in some cases, keloidal-like plaques on the occipital scalp and upper posterior neck.1 It is associated with pseudofolliculitis barbae, chronic scalp folliculitis, an increased risk of new-onset hypothyroidism, hidradenitis suppurativa, acanthosis nigricans, keratosis follicularis spinulosa decalvans, and metabolic syndrome.2-8 Some individuals may have a genetic predisposition to developing AKN.9 It can be seen in patients on cyclosporine, diphenylhydantoin, and carbamazepine.10 AKN can be characterized based on location of the lesions on the scalp, morphology of the lesions (ie, discrete or merged papules or nodules, plaques, or tumorous masses), and whether there is associated dissecting cellulitis of the scalp (DC) or folliculitis decalvans (FD).11 Therapy should be tailored to the stage of development in each affected patient, and any concomitant infection, if present, should be treated. See Table 84-1.

Table 84-1Acne Keloidalis Nuchae Treatment Table
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Table 84-1 Acne Keloidalis Nuchae Treatment Table
MEDICATION NAME INDICATIONa MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Steroids DP ≤3 mm Anti-inflammatory Class I or II corticosteroid gel/foam applied BID; 2 wk of application followed by 2 wk without application, for 8-12 wk Atrophy None IV12-15
Clindamycin DP ≤3 mm; pustules present Antibacterial, anti-inflammatory 1% foam, gel, lotion, solution; apply q12h-QD Skin irritation None IV16
Corticosteroid gel combined with retinoic acid gel DP ≤3 mm Anti-inflammatory; ECM repair properties Class II or III corticosteroid gel combined with retinoic acid gel applied BID; 2 wk of application followed by 2 wk without application, for 8-12 wk Skin irritation, atrophy None IV14,15
Imiquimod DP, MP Immunomodulator Applied for 5 d, followed by 2 d off, for a total of 8 wk. Can be used as monotherapy or combined with pimecrolimus. Skin irritation None IV14,17
Systemic Therapy
Minocycline DP, MP with secondary infection Antibacterial, anti-inflammatory 65 mg QD; 100 mg QD-BID Light-headedness, dizziness, vertigo None IV13
Doxycycline DP, MP with secondary infection Antibacterial, anti-inflammatory 40 mg QD; 100 mg QD-BID Photosensitivity GI upset, headache None IV13
Oral Steroids PQ, TM, large abscesses or draining sinuses Anti-inflammatory 7-10 d of prednisone given concomitantly with oral antibiotics Mood changes, weight gain None IV14
Low-dose isotretinoin DP, MP, PQ, and TM with folliculitis decalvans Anti-inflammatory 0.25-1 mg/kg QD; for up to 12 mo Teratogenic, skin dryness, nausea, increased lipid and liver enzymes CBC, CMP, lipid panel, pregnancy test at baseline, then q month until 1 month after reaching desired dosage IV18
Light, Lasers, and Radiation
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