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.

An initial staphylococcal folliculitis after short haircut or shaving is discussed. There is no pathogenetic relationship to acne (localization, absence of comedones). Due to an unknown cause, a transition into a chronic fibrosing inflammation with tissue hyperplasia and a reactive pressure atrophy of the follicles occurs.

Occurring only in males. Onset after puberty. People with dark skin color are affected more often (peculiarities of the hair structure).

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.

Furuncle: Highly painful, acute onset; originating from 1 follicle; no multiple pustules on the surface; markedly fluctuant.

Folliculitis decalvans: Eminently chronic course of the disease usually over years; scarring alopecia; highly red skin lesions in the center usually atrophic shiny and marginal standing follicular papules; later pustular transformation and crusting. Irregularly shaped foci of scarring with small-spotted, irreversible hair loss result. Formation of tufted hairs.

Tinea capitis profunda: Mostly occurring in children! Subacute or acute course; itchy or moderately painful, 0.5-5.0 cm in size, usually well demarcated, cushion-like raised, purulent, bright red plaques or nodules. Pus may be discharged on pressure. Hairs are absent from the lesion; hairs that still exist can be easily and usually painlessly extracted; preparation of a native specimen 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 intervals of weeks. In inflammatory phases, if necessary, local disinfectant solutions polihexanide (Serasept, Prontoderm), polyvidone-iodine solution (e.g. Betaisodona).

Small lesions should be excised en bloc, larger lesions should be covered with a full-thickness skin graft or stretch plastic.

Treatment with tetracyclines (e.g. Tetracycline Wolff) 4 times/day 250 mg p.o. or with isotretinoin (e.g. Isotretinoin-ratiopharm; Aknenormin) 0.5 mg/kg bw/day p.o. Caution! Women of childbearing age!

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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