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

• Acne keloidalis nuchae (AKN) is a form of folliculitis, which is chronic inflammation of the hair follicles. 
• AKN presents as itchy bumps around the back of the neck, which progress to scarring, lesions and hair loss. 
• Dark-skinned men are most likely to suffer from the condition.
• The cause of AKN is unknown but close shaving, haircuts, skin irritation and immune reactions are believed to contribute.
• Treatment options include over-the-counter and prescription medications, laser treatment and surgical management.

Acne keloidalis nuchae (AKN) is a chronic skin disease that inflames hair follicles around the nape of the neck. It is also known as folliculitis keloidalis or folliculitis keloidalis nuchae.

The condition occurs almost exclusively in dark-skinned men, although Caucasians and women may be affected. While the exact cause is unknown, dermatology theories point to haircuts, close shaving, skin irritations and immune reactions as contributing factors.

As well as being itchy and uncomfortable, AKN can be unsightly. It can also be difficult to treat. Treatment of AKN may include over-the-counter (OTC) and prescription medications, laser treatment and surgical procedures. These treatments have varying levels of success and it may take several months to see improvement.

What Is Acne Keloidalis Nuchae?

Despite the name, acne keloidalis nuchae is not a type of acne. It is actually a form of folliculitis, with symptoms that resemble acne vulgaris. It typically presents as small, itchy bumps around the hairline at the nape of the neck. Eventually, these bumps become scars and the hair around them can fall out. This is called scarring alopecia. The scars can also enlarge to form keloid-like papules or pustules, which look similar to acne. These symptoms can be uncomfortable, painful and distressing. As such, many sufferers experience reduced confidence and self-esteem.

What is folliculitis?

Folliculitis broadly refers to inflammation or infection of the hair follicle. Folliculitis is a common skin disease which can occur anywhere on the body where hair grows. It is often seen on the chest, back, legs and arms. It usually presents as a tender red spot with a superficial pustule around the hair follicle.

AKN is a special type of folliculitis, which inflames hair follicles at the back of the neck. In some cases, inflammation may extend from the hairline onto the occipital scalp. This type of folliculitis is comparatively rare and much harder to treat.

While common cases of folliculitis often clear up on their own, AKN requires specific treatment and management.

Causes of Acne Keloidalis Nuchae

The exact cause of AKN is unknown. However, there are several theories to explain the condition, including:

• Close shaving or haircuts
• Hats and clothing
• Hormones
• Immune reactions
• Genetics

Close shaving or hair cutting. Skin injuries can occur from close shaving or haircuts with a razor, which can destroy the hair follicle and cause inflammation. 

Hats and clothing. Helmets or collars worn close to the neck can pull on hairs and cause friction. This friction may be worsened by heat or sweating.

Hormones. AKN occurs almost exclusively in adult males, suggesting that androgens (sex hormones) may play a role either directly or indirectly.

Immune reactions. Antigens within hair follicles attract inflammatory cells, resulting in damage to the follicular wall and, eventually, hair loss (scarring alopecia).

Genetics. Genes that cause hair to have weaker follicles make some people more susceptible to AKN.

Who is at risk?

AKN effects between 0.45% and 9% of the population. It is most predominant among dark-skinned men, particularly those of African descent, although it can also affect Caucasians. The condition starts after adolescence and is rare after the age of 55 years.

Men with curly or kinky hair are particularly susceptible. While there is no direct link, it is thought this could be due to hair-cutting practices and trauma caused by using an electric razor. The curvature of the hair follicle in the skin may also be a factor. This is because curly African hair can excessively penetrate skin and lead to ingrown hairs. 

AKN is rarely seen in women, with men being more than 20 times likely to develop the condition. This supports the theory regarding hair-cutting practices, as women are less likely to close shave around the back of the neck. It also reinforces that hormones may play a role in the condition.

Over-the-Counter and Prescription Treatments

Over-the-counter (OTC) and prescription treatments for AKN include:

• Antimicrobial cleansers
• Triamcinolone cream
• Topical steroids
• Oral antibiotics
• Oral isotretinoin

Antimicrobial cleansers

Antimicrobial cleansers contain antiseptic ingredients like betadine or hydrogen peroxide, which destroy or reduce the growth of bacteria. This helps to heal lesions by controlling bacterial balance while also supporting the growth of new tissue. It also helps to decrease inflammation and secondary infections. 

Triamcinolone cream

Triamcinolone cream is a type of synthetic corticosteroid that is used to treat various skin conditions. It has strong anti-inflammatory properties that can reduce redness and relieve discomfort. Triamcinolone cream is most appropriate for smaller lesions which don’t respond to antimicrobial cleaners. For large, more inflamed lesions, a doctor or dermatologist may prescribe an oral triamcinolone formula or intralesional injections.

Topical steroids

Topical steroids are anti-inflammatory preparations available in creams, ointments, gels and foams. These are used to treat mild symptoms where there is no keloid formation. In a study of 20 African American men, foam topical steroid solutions were found to be an effective treatment for AKN over the course of 8-12 weeks. They may also be combined with topical retinoids, which regulate cell growth and can help maintain clear skin after successful treatment.

Oral antibiotics

Oral antibiotics are available via prescription for large, inflamed lesions. Popular oral antibiotics include doxycycline, minocycline and tetracycline, which have antibacterial and anti-inflammatory properties. These drugs fight infection and stop wounds from proliferating. They have been found to be an effective treatment for AKN and low doses may be continued for up to 12 months.

Oral isotretinion

Oral isotretinoin may be prescribed when patients aren’t responding to topical steroids or antibiotics. It is most commonly used to treat acne vulgaris but can also treat AKN by reducing inflammation and inhabiting the growth of bacteria.

The effectiveness of medications for AKN varies between individuals. In many cases, early lesions respond to treatment with minimal scarring. However, in some cases, it may take months of treatment to achieve incomplete results. Recurrences are also common.

In-Office Treatments

When symptoms don’t respond to OTC or prescription medications, patients may consider the following in-office treatments:

• Laser treatment
• Surgical treatment
• Radiotherapy

Laser treatment

There are different types of laser therapy to treat AKN. Laser hair removal works by destroying the hair follicles within lesions, which in turn reduces inflammation. Most people will need several sessions, spaced over a few weeks. This treatment can only commence once any infection has been treated.

Targeted ultraviolet B treatment also improves the appearance of papules without destroying the hair follicle. Studies have shown it takes around 16 weeks of therapy to see significant improvements.

One downside to laser treatments is that they can be costly.

Surgical procedures

Surgical procedures are reserved for patients with large, fibrotic lesions. Surgery is a last resort when other treatments are ineffective. 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 pierce the skin and remove lesions. Wounds are treated with medication before being stitched close.

In a surgical excision, a scalpel is used to remove the lesion. This procedure penetrates skin more deeply and prevents lesions from growing back. This procedure may also be performed using electrosurgery, which uses a high-frequency current (rather than a scalpel) to cut through tissue and remove lesions. In both methods, wounds are left open after treatment and may take months to heal.

While surgical management can produce excellent results and prevent AKN from recurring, it is only recommended for severe cases where quality of life is affected.

Radiotherapy

Recurrence of AKN is rare after surgery. However, radiotherapy may be used as a preventative measure post-surgery. It can also be used to improve the appearance of scarring. 

At-Home Treatments for Acne Keloidalis Nuchae

There are several natural ingredients that may be used to treat the condition at home. The most common at-home remedies include:

• Apple cider vinegar
• Aloe vera
• Tea tree oil

While these ingredients may reduce discomfort, they do not actually heal lesions. As such, they are most commonly used to complement OTC, prescription or in-office treatments. Before starting any at-home treatments, be sure to discuss potential risks and side effects with your doctor. 

Apple cider vinegar

Apple cider vinegar has anti-infective and antimicrobial properties. It has the potential to fight bacteria and reduce the risk of infection. To use, dilute 1 tablespoon of apple cider vinegar with 3 tablespoons of water, then apply directly to skin with a clean cotton pad.

Aloe vera

Aloe vera has proven medicinal properties. It has been used for decades to treat a variety skin conditions. While it does not directly heal AKN lesions, it may speed up the healing process by reducing inflammation and fighting bacteria. To use, apply a small amount of aloe vera gel directly to skin using a clean cotton pad.

Tea tree oil

Tea tree oil has antiseptic and antimicrobial properties that can kill bacteria and prevent infection. While it as not as fast-acting as pharmaceutical products, it is proven to reduce inflammation which, in turn, reduces discomfort of symptoms. To use, dilute 1 tablespoon of tea tree oil with 3 tablespoons of water, then apply directly to skin with a clean cotton pad.

What You Can Do To Prevent It

While treatment of AKN can be difficult, there are some measures you can take to reduce the risk of symptoms developing. If you’re already suffering from the condition, these simply lifestyle practices may also prevent symptoms from becoming worse. 

• Avoid close shaves or very short haircuts that can damage the nerve follicle.
• Avoid wearing clothing, hats or helmets that rub against the back of the neck.
• Avoid using hair products like hairsprays, gels or pomades, which can interfere with hair growth.
• Keep the back of your neck clean and dry.
• Be gentle when cleansing skin at the back of the neck, as rubbing too hard may cause irritation.

Takeaway

AKN is a chronic form of folliculitis, or infection of the hair follicle. It begins with itchy bumps around the back of the neck, along the hairline. These bumps can become scars, resulting in hair loss (known as scarring alopecia) and can also enlarge to form unsightly keloid-like papules and pustules.

The condition primarily effects dark-skinned men and is rarely seen in women. While the exact causes are unknown, there is a correlation between close shaving, hair-cutting and hats and clothing, which can cause friction against the skin. Other factors such as hormones and genetics may also contribute to the condition.

In terms of treatment, AKN can be difficult to resolve. Effective treatment options include OTC and prescription medications, in-office treatments and surgical management. The success of these treatments varies between individuals, but early intervention is important for the best results.

Regardless of the prescribed treatment options, there are some things you can do to reduce the risk and severity of symptoms. Avoid close shaving and short haircuts, minimise the use of hair products, and ensure skin around the back of the neck is kept dry and clean.