Acne Keloidalis Nuchae

A 53-year-old African American woman had a 5-year history of chronic scalp infections with numerous purulent drainage sites; she had undergone multiple incision and drainage procedures in the emergency department for scalp abscesses. Maintenance minocycline therapy had initially been prescribed after folliculitis barbae and a large cyst of the right posterior neck were diagnosed. At that time, no erythema or increased warmth of the area was noted; however, there was a large keloid on the occiput with a small amount of purulent drainage. No fluctuance was observed. She was referred for surgery, but she was considered a poor surgical candidate because of the location and size of the lesion.

The patient reported that the keloid had not grown or worsened since minocycline therapy was started 5 years ago. Physical examination revealed a 3-cm linear keloid on the right lower face/jawline and a soft, non-tender, non-pruritic, hypertrophic fungating mass from the nape of neck to the vertex involving all of patient’s posterior scalp. Minimal crusting without drainage was observed. Her neurological function and general examination results were within normal limits.

This patient has acne keloidalis nuchae. The pathology is most often seen in 13- to 25-year-old African American men, secondary to trauma to the occiput/scalp when their hair is cut or shaved.¹ Since this patient had a history of multiple incision and drainage procedures to treat scalp abscesses, the repeated trauma put her at risk for the development of the disease.

Possible therapies for acne keloidalis nuchae include topical, intralesional, or short-burst oral corticosteroids; topical or oral antibiotics; topical retinoids; surgical therapy, including excision; laser therapy; radiation therapy; and cryotherapy.¹ Minocycline was initially chosen for this patient to reduce inflammation and to treat a superimposed infection. Because she is not a good candidate for surgery and declines intralesional corticosteroid injections, she has been maintained on the tetracycline for control of inflammation.

The patient has permanent hair loss of the affected area and wears a wig. She is diligent in avoiding friction of the involved area, because she has been advised that irritation will aggravate and worsen the condition.²

The most common complication of this disorder is cosmetic disfigurement (worsening keloid plaques, scarring, chronic draining sinuses, and infection), and depression can occur as a result.¹ The recurrence rate depends on the therapy selected; however, keloids generally recur in about 50% to 80% of patients despite treatment.³

REFERENCES:

1. Letada PR, Satter EK, Patterson JW, et al. Medscape Reference. Acne Keloidalis Nuchae. August 5, 2011. Available at http://emedicine.medscape.com/article/1072149. Accessed March 26, 2013.

2. George AO, Akanji AO, Nduka EU, et al. Clinical, biochemical and morphologic features of acne keloidalis in a black population. Int J Dermatol. 1993;32(10):714-716.

3. Durani P, Bayat A. Levels of evidence for the treatment of keloid disease. J Plast Reconstr Aesthet Surg. 2008;61(1):4-17.

The author reports no financial disclosures or conflicts of interest.