Acne Keloidalis Nuchae: What It Is, Causes, Treatment Options and More

• Acne keloidalis nuchae is a form of folliculitis, a chronic inflammation of hair follicles 
• It presents as papules and pustules around the nape of the neck which can progress to keloid-like plaques, scarring and hair loss
• Causes include close shaving, repeated irritation, certain medications and genetics
• Treatment options include over-the-counter and prescription medications, laser treatment and surgery

Acne keloidalis nuchae, also known as keloidal folliculitis, is a chronic skin condition that is characterized by inflamed hair follicles around the nape of the neck. 

This condition occurs almost exclusively in young, African-American men, as well as men with coarse or curly hair, as this texture can trigger irritation and inflammation. It has also been linked to the presence of Staphylococcus aureus bacteria which worsens symptoms. 

What Is Acne Keloidalis Nuchae?

Acne keloidalis nuchae is a form of chronic folliculitis. Initial symptoms are characterized by small, red or pus-filled papules and pustules that develop along the hairline at the nape of the neck. These lesions are tender to the touch, itchy and unsightly. 

In advanced stages chronic inflammation leads to progressively larger and more painful tumor-like masses called plaques which can cause disfigurement and pain, as well as hair loss due to scarring. This is referred to as scarring alopecia. 

This scarring destroys hair follicles, which results in permanent hair loss. This type of folliculitis is comparatively rare and can be challenging to treat.

These symptoms can be distressing and have a negative impact on quality of life. Of note is that African American men have been found to have a disproportionately high level of chronic pruritic (itchy) disorders. They also experience greater levels of inflammation which explains in part why skin of color has a greater tendency to develop tumorous masses.

What is folliculitis?

Folliculitis refers to inflamed hair follicles that result from a bacterial or fungal infection. It commonly appears on the face, arms, back and legs, and where friction is present. It usually presents as a tender red spot with a superficial pustule around the hair follicle.

If mild, symptoms can resolve on their own; if not, a topical antibiotic can effectively treat the infection.

Acne keloidalis nuchae is a type of folliculitis, and inflames hair follicles at the back of the scalp; in some cases this inflammation can extend from the hairline to the lower-bottom of the scalp. 

This skin condition is uncomfortable and unsightly. It is important to see a doctor as soon as symptoms appear to treat the condition and prevent worsening symptoms; these include hard, raised plaque-like lesions which cause scarring and permanent hair loss.

Causes of Acne Keloidalis Nuchae

While the exact cause or origin of this skin condition have yet to be established, several factors have been identified as follows:

• Bacterial infections can cause inflammation within hair follicles 
• Close shaving can trigger chronic irritation or cause skin injuries
• Hair cutting can block the follicle openings; improper hair-cutting practices
• Hair slivers or splinters can result when a strand of newly-cut hair penetrates the top layer of the skin leading to infection
• Repeated friction brought on by tight-fitting shirt collars or headwear 

Other possible contributors to the development of acne keloidalis nuchae include systemic disorders such as hypothyroidism, excess androgens, autoimmunity and insulin resistance.

Lastly, heat and humidity can also exacerbate symptoms.

Who is at risk?

Acne keloidalis nuchae affects between 0.45% and 9% of the population. While there are cases among women, it is most prevalent among African Americans, with a male to female ratio of 20:1. This condition starts after adolescence and is rare after the age of 55 years.

African Americans typically have coarse or curly hair, and it is speculated that this type of hair can cause chronic irritation due to continuously rubbing against the nape of the neck or due to ingrown hair or slivers. This induces inflammation and the formation of lesions. 

Over-the-Counter and Prescription Treatments

Several oral and topical treatments are available to manage this skin condition. While difficult to treat, the prognosis is good if managed early as this can prevent symptoms from worsening and potentially causing permanent damage.

Treatment will be based on severity of the skin and will typically involve a combination of topicals, intralesional injections, and systemic steroids and retinoids to target inflammation and heal lesions. Oral antibiotics can also heal any active infections.

Corticosteroids

Topical corticosteroids (steroids) are valued for their anti-inflammatory properties and can be used as a sole treatment or alongside other treatments for greater results. Topical steroids are most effective for small papules; short-term use of oral corticosteroids are effective for large, inflamed lesions.

Triamcinolone 

Triamcinolone is a synthetic corticosteroid that is available in various topical forms including creams, lotions and ointments; and as a nasal spray and injectable. It is commonly prescribed to treat such skin conditions such as atopic and contact dermatitis, eczema and psoriasis. 

This medication is formulated to reduce inflammation and control an overactive immune system and as such, is appropriate for acne keloidalis nuchae.

An oral triamcinolone formula or intralesional injections can soften and reduce the size of large papules and nodules that present in more severe cases.

Oral antibiotics

Oral antibiotics are added to a treatment regimen when there is an infection; this targets inflammation and aids in relieving symptoms.

These medications are available by prescription; they fight infection and halt the progress of skin damage. Doxycycline, minocycline and especially tetracycline have been found to be effective in killing bacteria, addressing inflammation and healing lesions.  

Topical and oral retinoids

Retinoids, such as tretinoin, tazarotene or adapalene work to regulate cell overgrowth, calm inflammation and reduce papule count and size.

Oral isotretinoin

Oral isotretinoin is prescribed for severe cases or when patients fail to respond adequately to more conventional therapies. It effectively reduces inflammation and inhibits the growth of bacteria. As well, it encourages skin cell renewal which helps rid the skin of damaged skin cells.

Antimicrobial cleansers

Once acne keloidalis nuchae is successfully controlled, antimicrobial cleansers that contain antiseptic ingredients such as betadine or hydrogen peroxide can be used as maintenance therapy to destroy microorganisms (including bacteria), decrease inflammation and heal lesions. 

In-Office Treatments

Other treatments are available to manage acne keloidalis nuchae; they can be used together with traditional treatments or after a course of treatment to maintain results.

Laser therapy

Laser therapy can effectively destroy hair follicles and decrease the inflammatory response.

Two lasers have been effective in reducing symptoms and severity in this skin condition. In studies, the CO₂ laser produced therapeutic responses ranging from 82–95% and the Nd:YAG laser enabled a significant decrease in papule and pustule count. This laser also reduced the size of keloids and softened them.

Targeted ultraviolet B treatment (tUVB), a form of light therapy, has been shown to significantly decrease lesion count in 16 weeks.

Surgical procedures

Surgical procedures are reserved for patients with large, keloid-like plaques referred to as tumor-staged acne keloidalis nuchae.

There are two main types of surgical procedures – surgical punches and surgical excisions.

In a surgical punch, otherwise known as a skin punch or punch biopsy, a circular blade is used to penetrate deep into tissue and remove the entire hair follicle. It is considered a relatively simple technique and is less invasive than a surgical excision. 

In a surgical excision, a scalpel is used to remove the tumors. This procedure penetrates skin more deeply and can successfully prevent recurring tumors from recurring. Wounds are sutured or left open depending on the extent of the wound; antibiotics and pain medication are typically administered.

This procedure may also be performed using electrosurgery, which uses a high-frequency current to cut through large masses.

At-Home Treatments for Acne Keloidalis Nuchae

There are several natural ingredients that can reduce uncomfortable symptoms but they are not meant to replace professional treatments: acne keloidalis nuchae requires prompt and professional treatment to prevent symptoms from progressing.

 The most common at-home remedies include:

• Apple cider vinegar can kill bacteria and reduce swelling and inflammation; combine 1 tbsp vinegar with 3 tbsp water and apply to the affected area using a cotton ball
• Aloe vera has antibacterial and anti-inflammatory properties; apply to skin using a cotton pad or ball
• Tea tree oil can soothe inflammation, disinfect the skin and alleviate pain. It must be diluted before use. Combine 12 drops of a carrier oil with 1–2 drops of oil and apply to skin using a cotton ball

Acne Keloidalis Nuchae Prevention

For those that are susceptible to this skin condition, there are preventative measures that can help minimize symptoms or prevent this condition from developing altogether.

• Regularly wash the nape of your neck using an antimicrobial cleanser such as benzoyl peroxide; keep this area clean and dry
• Consider skin care products that contain alpha-hydroxy acids or glycolic acid to soften coarse hair
• Avoid close shaves and frequent haircuts; ensure proper hair-cutting techniques
• Avoid wearing tight-fitting shirt collars, hats or caps

Takeaway

Acne keloidalis nuchae is a chronic inflammatory skin condition that is caused by persistent folliculitis, inflamed hair follicles around the nape of the neck. In the early stage, it presents as small, red or pus-filled papules and pustules that are itchy and uncomfortable.

In advanced stages, this inflammation leads to large and painful tumor-like plaques which cause disfigurement and permanent hair loss due to scarring. This has a significant impact on quality of life.

The condition primarily affects young African Americans and is linked to ingrown hair, prolonged friction and irritation caused by close-fitting headwear and clothing. It is also linked to inflammation, infection and skin injury; other factors such as hormones and genetics may also be contributing factors.

Acne keloidalis nuchae is difficult to treat, especially once the condition becomes severe. Early intervention is therefore key. Treatment options include over-the-counter and prescription medications, in-office treatments and surgical procedures. Following some preventative measures can also reduce the likelihood of this condition developing.