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Acne keloidalis nuchae (AKN) is also commonly known as nuchal keloidal acne or keloidal folliculitis.
The characteristic features of acne keloidalis nuchae (AKN) include follicular-based papules and pustules. They eventually lead to keloidal-like or hypertrophic scars. AKN is a condition found primarily on young African American men and less commonly in young adult men of Latino or Asian descent and affects their occipital scalp and posterior neck. It is sporadic for women to suffer from acne keloidalis nuchae. Also, the chances of AKN decrease after puberty or middle age. The term acne keloidalis nuchae can be quite misleading as the lesions are not caused by acne vulgaris but result from folliculitis. The lesions are also not keloidal in nature.
5 Causes of Acne Keloidalis Nuchae
The cause of acne keloidalis nuchae is not precisely known, but males with darker skin (predominantly African descent) are more likely to develop AKN. It is also prone in men with curly or stiff hair. A few possible causes of acne keloidalis nuchae, as defined by researchers, are:
- Close shaving- It can lead to injuries that cause inflammation and thus destroys the hair follicles.
- Certain medications- some people showed signs of acne keloidalis nuchae after the consumption of cyclosporine, which helps with rheumatoid arthritis and psoriasis. Another medication linked with AKN is antiepileptic drugs.
- Constant irritation- Shirt collars and helmets irritate the hair on our scalp and neck, added on by the heat and humidity. It can thus lead to folliculitis and eventually scarring.
- Genetic mutations- A mutation that reduces the strength of hair follicles can also play a role in AKN.
- Chronic infection- Some chronic conditions, though low-grade in nature, can cause acne keloidalis nuchae.
Risk factors associated with Acne Keloidalis Nuchae
- Family history of the individual
- The male sex is 20 times more likely to suffer from AKN
- People in their adolescence or early adulthood
- Dark-colored skin
- Curly and stiff hair quality
- Hormones like testosterone
- Aggressive scalp treatments like close shaving and short hair cuts
Natural stages of development of Acne Keloidalis Nuchae
- It begins with the formation of red and inflamed raised bumps.
- Followed by secondary infection
- Patients can also have abscess formation.
- If the inflammation continues, it can lead to more scarring and larger scar masses.
- The end-stage is alopecia or hair loss.
Acne keloidalis nuchae is a disease caused mainly in men (though a few rare women may be suffering from AKN). So it can be directly linked to androgens. The age range for AKN is from after puberty to before 55 years. Regular shave haircuts are unavoidable for children in schools, but it does not cause AKN as it does not manifest before puberty. But after puberty, as there is an increase in the sensitivity of androgen receptors of the follicles and the activity of the sebaceous glands, it can cause AKN. We also see a spike in the hormone levels as an added effect.
Geneticity is also considered for AKN as men of African descent mostly have AKN. It relates to their hair quality and the curvature of the hair follicle. The terminal of the African hair has a sharp cut that produces extrafollicular and transfollicular penetration of the skin. Thus it can lead to ingrown hairs and pseudofolliculitis barbae (beard area).
Thus it can be considered as an etiology for acne keloidalis nuchae. After a haircut, the follicles are irritated due to the ingrown hair, which causes chronic inflammation. But histology of AKN lesions tends to suggest otherwise. It does not support the theory of ingrown hairs causing inflammation. The dermoscopic findings also do not support the idea of ingrown hairs found in people with pseudofolliculitis barbae. Also, an individual with AKN does not necessarily have pseudofolliculitis barbae and vice versa.
How to Manage Acne Keloidalis Nuchae?
Managing acne keloidalis nuchae can be very difficult in developing countries. Most men try to self-medicate, treating it like regular acne or consult quacks, which can worsen matters. As the lesions become unsightly, then only do they visit a doctor.
Some people believe it to be a common infection caused due to the barber’s instrument. So they tend to treat themselves using antibiotics available commonly, and thus adding to the antibiotic resistance. Some tend to use corrosives like acids and car engine oils to manage acne keloidalis nuchae. The quacks also recommend liquid nitrogen, which ends up giving scars to the patient.
Hence, therapy should be the way to go. Its goal is to curb the development of keloid-like lesions, which are most of the time followed by alopecia. Most patients are more afraid of the formation of keloidal lesions. As a measure of acne keloidalis nuchae, you must avoid irritation from tight shirt collars, close shaves, and helmets. Patients should also not get a haircut when their lesions bleed easily. They should also not shave the affected areas to increase medication absorption as it will just increase the irritation. Use shampoos with tar or antiseptic to prevent secondary bacterial infection.
6 Effective Treatment for Acne Keloidalis Nuchae
#1 Topical treatments
Use potent topical steroids to treat the early stage of acne keloidalis nuchae with non-keloidal lesions. You can also use topical retinoids along with steroids. To culminate the side effects of long-term use of the steroids, use them for two weeks straight and then give it a rest for the next two weeks. Reducing the steroid strength helps to decrease the lesion count. If you are suffering from postular lesions, use both topical clindamycin and topical steroids.
#2 Intralesional steroids
Another way to manage mild to moderate acne keloidalis nuchae is by using intralesional injections. They must be of long-acting steroids, triamcinolone. We recommend a dose of 5-40 mg/mL. If you go for higher amounts, they will provide a quicker response to the fibrotic lesions but increase the side effects like atrophy. So dilute the steroid to reduce atrophy and transient hypopigmentation.
The intralesional steroid injections can be quite painful for a person suffering from keloidal-like lesions. To better perform the drug, you can either dilute the steroids or inject a ring of xylocaine around the lesions. It helps the patient accept the drug quickly. You must administer the injections at intervals of 4 weeks and not a day before that.
A way to make intralesional injections easier is cryotherapy. It softens the keloidal lesions, which are in the early stages.
#3 Systemic therapy
Systemic therapy is a method that uses antibiotics in the long term. It includes tetracycline derivatives and retinoids. If a patient having acne keloidalis nuchae has either postules, fistula, or sinuses, it can either mean that he/ she also has a secondary bacterial infection or folliculitis decalvans. So in addition, it will require antibiotics along with steroid therapy. You can start the antibiotics a few days before or on the same day as the steroid therapy.
A few oral antibiotics are doxycycline, minocycline, and tetracycline. They are derivatives of tetracycline and have anti-inflammatory and antibacterial effects. So the drugs reduce infection as the lesions respond well to them. Pain also reduces though bleeding of fibrotic lesions may continue. Patients with associated folliculitis decalvans can consume oral retinoids for up to a year.
#4 Surgical treatment
When a patient does not respond well to the above therapy treatments, surgery is the way to go. We also suggest it for patients with large fibrotic lesions. In the process, we use punch biopsy needles to remove the fibrotic papules. We should do it very carefully to ensure the removal of the entire follicle to prevent a repeat of papule growth.
A second method is the excision of the horizontal ellipse. It involves the entire length from the posterior hairline to the subcutaneous tissue, which may be closed primarily or left to heal automatically. Followed by this are the electro and cryo surgeries to remove the fibrotic lesions. Allowing the wound to heal by secondary intentions is also effective and causes fewer recurrences of acne keloidalis nuchae. We can also use postsurgical radiotherapy to reduce the chances of recurrence.
But the probability of recurrence of AKN is already low after surgical excision as compared to actual keloids.
#5 LASER and light therapy
To reduce lesion count and size, laser therapy is the latest therapy plan. It involves 1064 nm Nd: YAG and 810 diode lasers to treat patients with AKN. To destroy the hair follicles in the lesions that lead to inflammation, we use 1064 nm Nd: YAG. It works best for refractory cases, and you can use it along with topical steroids and retinoids. Carbon dioxide laser can also improve lesions of AKN.
Radiation therapy using targeted ultraviolet B radiation also helps in minimizing fibrotic papules. The patient showed signs of improvement after 16 weeks, but not as well as the laser treatment.
If the patient has an early stage of AKN, he should opt for medical treatment. The lesions respond well, and the treatment causes minimum scarring. It is easier to manage surgical excision with healing combined with secondary intension. The most promising is the 1064 nm Nd: YAG and 810 nm diode lasers. Though effective, it is pretty expensive, making it affordable only by the well-off.
Enhancing healthcare team outcomes
A patient must be assigned with an interprofessional team of nurses, pharmacists, and clinicians to manage Acne Keloidalis Nuchae. All patients do not respond to the same treatment, making AKN quite challenging to treat. The primary step must be to inform the patient of all the triggering factors and ways to get rid of them.
Educating the patient should be the foremost step as it helps reduce inflammation and get rid of factors causing the acne keloidalis nuchae. A few guidelines are avoiding to scratch or rub the affected area and also stop shaving and trimming.
Like any other disease, if we catch AKN early on, the prognosis expected is good. But if diagnosed at a later stage, the treatment process can be long and complicated after the formation of scars. Patients can also face cosmetic problems. The scarring and plaques can leave behind marks, which makes most males shy about their bodies. They lose confidence and may become withdrawn and depressed.
Another effect can be pruritus or scarring alopecia. If the patient continues to scratch the papules, they may break and lead to drainage.
Over-the-counter treatments of Acne Keloidalis Nuchae
You can also look into over-the-counter treatments recommended by your doctor to help deal with your acne keloidalis nuchae and soothe the pain. Some of them are:
A readily available option is tar shampoo or coal tar shampoo, as it is known as commonly. It contains keratoplastics that can help in relieving itchy skin conditions. They do this by shedding the dead skin cells and curbing the growth of new ones, which soothes itchiness.
Soaps are a significant and easy way to prevent acne keloidalis nuchae. It keeps the area clean and prevents infections. Go for soaps that contain benzoyl peroxide or chlorhexidine. These are antimicrobial cleansers that help with AKN.
Consult your doctor on how to use the soap safely.
Everyday Tips for dealing with Acne Keloidalis Nuchae
Follow the following guidelines to keep the acne keloidalis nuchae under control and stop it from getting worse.
- Wear shirts and jackets without collars as they tend to rub against the nape of your neck.
- Don’t use products that interfere with hair growth like pomade and hair grease.
- It would be best if you also avoided hats and helmets as they cause friction on the back of the head.
- Avoid short haircuts or close shaves to protect your hair follicles.
- Give special attention to the cleanliness of your neck and scalp.
- Keep in mind not to rub your skin too hard to prevent irritation.
Acne keloidalis nuchae do not have a researched cure or cause, but we can curb it by using directed preventative measures and various treatments that work best for you. You should consult a doctor at once on the early signs of acne keloidalis nuchae.
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