Acne keloidalis nuchae L73.0

Eminently chronic fibrosing and indurating folliculitis and perifolliculitis of the neck region, leading to irreversible hair loss and progressive, extensive, bulging keloid scarring.

Etio: discussed is an initial staphylococcal folliculitis after short haircut or shaving. There is no pathogenetic relationship to acne (localization, absence of comedones). From unknown cause transition to a chronic fibrosing process with tissue hyperplasia and pressure atrophy of the follicles.

Occurs only in men, after the age of puberty; preferred in people with dark skin.

Initially individual, small, red, follicular papules and pustules, from which develop hard, dark red, hemispherical, shiny, differently sized, solid papules and nodules pierced by a terminal or vellus hair, which can confluent to form larger plate-like structures.

Later increasing sclerotic, almost board-like hardening of the skin between them.

Beam-like, transverse, coarse, bulging keloids with tufts of hair.

Deep epithelium-lined fistula ducts.

Peripheral continuous sometimes intermittent progression of the sclerosing inflammation over a period of years.

• Boils: Highly painful, acute; starting from 1 follicle; no multiple pustules on the surface; clearly fluctuating.
• Folliculitis decalvans: Eminently chronic course of the disease mostly over years; scarred alopecia; highly red skin changes in the centre mostly atrophic shiny and peripheral follicular papules; later pustular transformation and crust formation. Irregularly shaped scar foci with small spots of irreversible hair loss result. Formation of tuft hairs.
• Tinea capitis profunda: Mostly occurring in children! Subacute or acute course; itchy or moderately painful, 0.5-5.0 cm large, usually well defined, cushion-like raised, purulent, highly red plaques or nodules. Pus can be emptied under pressure. Hair is missing in the lesion; existing hair can be easily and usually painlessly extracted; preparation of a native preparation for fungal detection.

• Intralesional injections with glucocorticoids such as triamcinolone acetonide (e.g. Volon A 10 crystal suspension) diluted 1:3 to 1:5 with physiological NaCl solution or local anaesthetic such as mepivacaine, several times at weekly intervals. In inflammatory phases local disinfectant solutions polihexanide (Serasept, Prontoderm), polyvidon iodine solution(e.g. Betaisodona).
• Excise small foci en bloc, cover larger foci plastically after excision with a full-thickness skin graft or stretching plastic surgery.
• Treatment trial with tetracyclines (e.g. tetracycline Wolff) 4 times/day 250 mg p.o. or with isotretinoin (e.g. isotretinoin-ratiopharm; acne normin) 0.5 mg/kg bw/day p.o. Cave! Women of childbearing age!

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2. Alexis A et al (2014) Folliculitis keloidalis nuchae and pseudofolliculitis barbae: are prevention and effective treatment within reach? Dermatol Clin 32:183-191
3. Gloster HM Jr (2000) The surgical management of extensive cases of acne keloidalis nuchae. Arch Dermatol 136: 1376-1379
4. Hebra v. F, Kaposi M (1860) Textbook on skin diseases. Enke, Erlangen, vol. 1, p. 506
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7. Sparrow LC (2000) Acne keloidalis is a form of primary scarring alopecia. Arch Dermatol 136: 479-484

8. Shapero J et al (2011) Acne keloidalis nuchae is scar and keloid formation condary
   to mechanically induced folliculitis. J Cutan Med Surg 15:238-240