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Case Note

Case Note: Pustules and Scarring on the Back of the Neck

History

A 22-year-old black male, with no significant past medical history, presents for management of pustules and scarring on the back of the neck.

Initial evaluation

  • Patient takes no medications
  • Presents for management of a firm keloidal plaque (5x2 cm) on the nape - present for several years
    • Studded with pustules
    • Associated with hair loss and dolls' hair tufting
  • Review of systems is notable only for discomfort, intermittent bleeding, and purulent discharge associated with the rash
    • Patient denies a history of prior keloidal scarring, skin infections, or alopecia
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Enter your diagnosis

Diagnosis

  • A diagnosis of acne keloidalis nuchae is rendered

Initial Treatment

  • A bacterial culture of a pustule is performed
  • Doxycycline 100 mg twice daily and benzoyl peroxide wash 5% is prescribed
  • Follow up in 3 weeks

Follow-up evaluation strategy

Follow-up evaluation:

  • The neck eruption shows improvement, with only several active pustules present
  • The bacterial culture taken at the initial evaluation revealed only normal skin flora, so the doxycycline is discontinued
    • The benzoyl peroxide wash is continued
  • Follow up in 4 weeks

Subsequent follow-up evaluation:

  • The patient reports that he is disturbed by the cosmetic appearance of the neck plaque, so after extensive counseling, he opts to have surgical resection of the plaque
  • Upon resection, the patient returns for intermittent intralesional triamcinolone acetonide injections with excellent clinical and cosmetic outcome

Further recommendations:

  • If active folliculitis is present, culture the lesions for bacteria and prescribe an oral antibiotic such as tetracycline 500 mg twice daily, doxycycline 50-100 mg twice daily (as was prescribed in this present case note) or minocycline 50-100 mg twice daily
  • Local phototherapy (UVB) may be effective to reduce inflammation at the site

Subsequent treatment steps:

  • If active folliculitis persists, reculture the lesions and choose an alternative antibiotic as indicated by the result of culture and sensitivity
  • If papules do not regress, increase the strength of the intralesional triamcinolone acetonide to 20 mg per cc initially and then to 40 mg per cc if necessary
  • It may be necessary to continue topical benzoyl peroxide and/or appropriate antibiotic therapy indefinitely
  • Patients should avoid greasy hair products that may occlude the skin, resulting in occlusive folliculitis
  • Neck hair should not be trimmed very close to the skin
    • Frictional exacerbation, stemming from use of electric clippers or razors, as well as trauma to the skin at this site, may contribute to disease flares
    • Laser epilation may be a highly effective strategy for eliminating the hair present at the site, likely the inciting cause of the folliculitis
  • Most persistent or extensive cases are best managed by surgical techniques (a treatment option implemented in this present case note)
    • Small individual lesions may be removed by punch biopsy excision and sutured closed
    • Larger lesions may be removed by surgical excision
      • Scalpel or laser surgery may be used
      • Healing may be by second intention or by primary closure
      • If the defect is closed primarily, tension should be minimal to prevent a spread scar and keloid formation
      • A tissue expander may provide adequate tissue for primary closure of large lesions
  • If surgical removal is performed, intralesional injection of triamcinolone into the scar may be required postoperatively

General discussion

Acne keloidalis nuchae primarily affects the nape of dark-skinned individuals with curly hair - primarily black men. The disease is a form of follicular inflammation with excessive scarring, which represents a keloidal reaction to prior or ongoing folliculitis. Irreversible alopecia will result in the setting of chronic disease. The role of local trauma, particularly bleeding, within areas of folliculitis has been suggested by patient cohort studies. Patients may or may not form hypertrophic scars or keloids at other sites.

The strategy of therapy is to treat active folliculitis, if present, and to reduce hypertrophic hair fragment-induced scars. This can be done utilizing medical therapy, primarily topical antimicrobial agents and systemic antibiotics, or through surgical strategies, including excision. There may be a role for phototherapy as well as laser epilation of the hair.

Further reading

Alexis A, et al. Folliculitis keloidalis nuchae and pseudofolliculitis barbae: are prevention and effective treatment within reach? Derm Clin 2014;32:183-91.

Esmat SM, et al. The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae: a pilot study. Eur J Dermatol 2012;22:645-50.

Khumalo NP, et al. Folliculitis keloidalis nuchae is associated with the risk for bleeding from haircuts. Int J Dermatol 2011;50:1212-6.

Kundu RV, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominately in skin of color. Am Fam Phys 2013;87:859-65.

Loayza E, et al. Acne keloidalis nuchae in Latin American women. Int J Dermatol 2015;54:e183-5.

Okoye GA, et al. Improving acne keloidalis nuchae with targeted ultraviolet B treatment: a prospective, randomized, split-scalp comparison study. Br J Dermatol 2014;171:1156-63.

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