Acne Keloidalis Nuchae

Clinical Features and Trichoscopy Findings

AKN occurs almost exclusively in men after puberty and is especially common in people with coarse, tightly curled hair:

• Location: Typically confined to the posterior hairline (nuchal area) and lower occipital scalp. Lesions rarely extend to the crown or temples.
• How it progresses:
  • Early stage: Firm red or skin-colored papules, 1–4 mm, clustered around hair shafts. There may be small pustules along with intense itching or mild pain.
  • Late stage: The papules merge into firm hypertrophic scar plaques with a smooth, shiny surface and no visible follicular openings. Severe cases form a large keloidal band across the nape, which may ooze foul-smelling pus from secondary infection within the scar folds.
• Trichoscopy (scalp dermoscopy) features:
  • Perifollicular erythema and papules: Mild redness around the hair openings with surrounding scale.
  • Ingrown or infolded hairs: Hair shafts that are bent at an angle or run sideways into the epidermis.
  • Ivory-white fibrotic areas with loss of follicular openings: The scarred surface has no follicular openings left, and ivory-white fibrous bands stand out against the surrounding skin.
  • Tufting: In some intermediate-stage cases, 2–4 hairs emerge together from a single point at the edge of a scar.

Our Approach and Treatment Options

Because AKN combines mechanically triggered inflammation, secondary infection and fibrous scarring, Haute-Derma's management centers on four main approaches rather than a single fixed protocol:

Eliminating Risk Factors and Mechanical Trauma

• Change how the hair is cut: Patients should stop shaving the nape with a razor or close-cutting clippers altogether, and keep the hair at the nape at least 2–3 mm long.
• Remove sources of friction: Avoid stiff, high collars and necklaces or jewelry that rub the nape, and try not to scratch or rub the scalp.
• Regular antiseptic cleansing: Use scalp cleansers with a mild antiseptic to reduce the bacterial load around the follicles.

Controlling Inflammation and Infection (Papule/Pustule Stage)

• Topical anti-inflammatory therapy and micro-injections: Anti-inflammatory agents are applied to, or injected directly into, the inflamed perifollicular papules to quickly shut down the white-cell infiltrate and ease tenderness.
• Systemic microbial control: During flares with pustules or oozing, oral antibacterial agents help reduce the burden of Staphylococcus aureus and prevent abscess formation.
• Normalizing follicular keratinization: Topical keratolytic and keratin-regulating agents soften keratin plugs, free trapped hair tips and lower the risk of follicle rupture.

Reducing and Softening Scar Tissue (Hypertrophic Scar Stage)

• Intralesional therapy: Injections directly into the hypertrophic scar inhibit fibroblast proliferation and promote breakdown of excess collagen, flattening and softening the scar.
• Vascular laser and light therapy (PDL): Light energy targets hemoglobin in the vessels feeding the scar, reducing redness and itching and shrinking scars that are still actively growing.

Surgery and Laser Hair Removal (Refractory Disease / Bulky Scars)

• Laser hair removal (1064 nm Nd:YAG): Considered the cornerstone of long-term management. The laser destroys the hair follicles on the nape at their root, removing the hair that triggers the foreign-body reaction.
• Surgical excision or deroofing: Reserved for very large keloidal masses that deform the nape or fail to respond to medical treatment. The doctor removes the entire scar down to the muscle fascia and either closes the wound or lets it heal by secondary intention.

Differentiating Scarring Alopecias of the Nape and Occiput