22-Year-Old Male with Firm, Itchy Papules, and Hair Loss on the Occipital Scalp

Abstract

Acne keloidalis nuchae (AKN) is a rare cicatricial alopecia that typically affects young African-American males. While the pathophysiology is not well described, there are several competing theories to explain the phenomenon including foreign body reactions to hair, lichen simplex chronicus, or a subtype of acne mechanica. The most accepted pathophysiology involves chronic folliculitis in genetically susceptible patients that is exacerbated by excoriations and continued inflammation. Diagnosis of AKN is usually clinical, and presentation is often described in stages from the nape of the neck to the vertex of the scalp. Physical exam will reveal papules and pustules of various sizes that may coalesce into plaques. These lesions can be accompanied by excoriations. There may also be overlying signs of bacterial infection secondary to trauma. Severe manifestations will be characterized by large smooth plaques that extend beyond the borders of the original pathology. While not required, dermoscopy and histopathology can help diagnose AKN. No standardized treatment regimen currently exists for AKN. The primary focus should be placed on preventing further trauma to pre-existing lesions. Moreover, antibacterial cleaners can be useful in reducing bacterial burden and subsequent infection. In early stages, treatment can begin with topical corticosteroids. Intralesional triamcinolone can be used for larger papules and plaques. Other potential medications include topical retinoids, topical clindamycin, or systemic tetracyclines. AKN characterized as “tumor stage” may require surgical intervention, and several approaches exist. The primarily described approach includes horizontal elliptical excision with healing by secondary intention. This treatment has been expanded upon to include possible staged excisions utilizing skin grafts or varying excision approaches including the occipital protuberance. Breakthrough papule formation can be treated with high potency topical corticosteroids or intralesional steroids. Treatment of AKN largely depends on the physical presentation and desired cosmesis.KeywordsAcne keloidalis nuchaeCicatricial alopeciaChronic folliculitisSpade sign