Dermatologic Therapy, Vol. 20, 2007, 128–132 Copyright © Blackwell Publishing, Inc., 2007 Printed in the United States · All rights reserved DERMATOLOGIC THERAPY ISSN 1396-0296 Blackwell Publishing Inc keloidalis nuchae

Acne keloidalis nuchae, also known as its antimicrobial and antiinflammatory effect), nuchae, is a chronic scarring folliculitis charac- and a series of intralesional steroids (40 mg/cc of terized by fibrotic papules and nodules of the existing ). Education is the key to preven- nape of the neck and the occiput. It particularly tion. I discourage high-collared shirts, short - affects young men of African descent and rarely cuts, and close or cutting the hair along occurs in women; in either case its occurrence the posterior hairline. In the long-term, patients has a significant impact on the patient’s quality benefit from laser using diode or of life. We’ve asked our experts to share their expe- Nd:YAG, which helps avoid disease progression. rience in helping patients with this cosmetically Early treatment decreases the morbidity that can disfiguring disorder. be associated with late-stage disease.

Question Dr. Vause: I treat early acne keloidalis nuchae by instructing patients to wash the skin frequently Please describe your approach to the treatment of with a mild keratolytic like tar or an alpha hydroxy patients with early (less than 20 papules, pustules acid cleanser. Patients are instructed to apply and 1–2 < 2 cm nuchae keloids) acne keloidalis topical clindamycin with steroid in the morning nuchae. (1–3) and retinoid at bedtime. Dr. Brauner: An option is to treat all patients with Response chlorhexadine cleanser as a daily and minocycline 100 mg daily b.i.d. or Duricef (generic) Dr. Quarles: If the papules are small and barely 500 twice daily, or erythromycin 250 mg (after cul- raised, I generally prescribe a potent/superpotent turing pustules). Rifampin is reported to be helpful. topical fluorinated corticosteroid in ointment, I inject all papules with triamcinolone acetonide , solution, or foam formulations for nightly 3–5-mg/cc increasing to 40 mg/cc for more resis- application. Letting the patient choose the vehicle tant lesions. If there is formation or hyper- helps with compliance. If pustules are present, I’ll trophic scars, debulkment with a CO laser followed include a topical antibiotic solution or foam, pre- 2 by triamcinolone injections is very beneficial. I ferably, clindamycin, which is applied twice daily. stress to patients the importance of discontinuing Intralesional triamcinolone acetonide 40 mg/cc is all hair greases or pomades. injected into the more raised papules and repeated on subsequent office visits as needed. Systemic Dr. Breadon: The first step in treating patients antibiotics, preferably tetracycline 500 mg twice daily with acne keloidalis nuchae is educating . . . “No, is reserved for patients with numerous pustular it’s not caused by the ’s dirty clippers,” etc. I lesions. Recently, I have begun weaning patients also recommend wearing soft or no-collar shirts down to lower dosages of doxycycline (40 mg daily) whenever possible. I start patients on a combi- for maintenance therapy, following a trend toward nation of mid-potency topical steroid and topical treating aggressively early, which has yielded better antibiotic, such as fluocinonide cream and clin- results than the converse. Follow-up appointments damycin solution, or chloramphenicol powdered are every 4–6 weeks for 6 months until the active into the steroid cream, at 300 mg powder to 60-g phase is in remission then every 6 months. steroid cream applied daily for 4 weeks. With this approach, I ease the patient into the next level of Dr. Brody: My preference for treating early or treatment, which consists of monthly intralesional mild acne keloidalis nuchae is injecting 3 mg/cc triamcinolone, 10 mg/cc, into (and not under) the intralesional triamcinolone. individual lesions.

Dr. Badreshia: Initially, I treat acne keloidalis Dr. Swinehart: Acne keloidalis nuchae can be nuchae with topical steroids, oral doxycycline (for treated with trimethoprim or isotretinoin in an

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Dr. Brauner: Lesions respond to debulking and

CO2 laser excision to the fat followed by surgical site granulation.

Dr. Breadon: Inflammation at any stage is treated with a tetracycline (or derivative) antibiotic twice daily (usually doxycycline, at 100–200 mg per day, or minocycline, 75–100 mg twice daily). The newer gentle foaming benzoyl peroxide or sulfur-based washes, or Phisohex cleanser is suggested. I inject intralesional triamcinolone 10 mg/cc into smaller papules and pustules. In patients with keloidal nodules and plaques, 20 mg/cc is used. Sometimes I gingerly pretreat these lesions with liquid nitrogen FIG. 2. Mild acne keloidalis nuchae. before injecting to facilitate intralesional injections into large, firm lesions, whereas avoiding potential attempt to first clear the acne. Ingrown , if complications of secondary dyschromia. present, can be treated surgically. Question Dr. Epps: I prescribe class 2 or 3 topical steroids in addition to administering intralesional steroids. Are there any surgical or other interventions that If there are inflamed pustules, my prescription you find helpful in severe acne keloidalis nuchae? includes oral or topical antibiotics. Response Question Dr. Quarles: For patients with severe acne keloidalis How do you treat patients with more severe disease nuchae, primary excision with secondary inten- characterized by keloidal nodules and coalescent tion healing has been effective with no recurrence plaques? going after 15 years. I discourage surgical inter- vention for any inflammatory problems on hair- Response bearing areas whether on the scalp or groin as a result of poor wound healing and persistent Dr. Quarles: Severe disease requires even more excessive granulation that can result as wounds aggressive therapy. I prescribe prednisone 40 mg heal in these areas. Radiation therapy immedi- or 60 mg tapering by 5 mg each morning. In my ately postoperation is useful; however, the results opinion, cryotherapy is not indicated and can are mostly palliative. I have not seen or experi- cause unsightly hypopigmentaion, especially, in enced any better results with the use of lasers in patients with skin type VI. the treatment of this disease when compared to surgical intervention. Neither am I convinced that Dr. Brody: Shaving lesions followed by intra- lasers play much of a definitive role in the treat- lesional steroids works well. ment of scarring follicular disorders, except, pos- sibly psuedofolliculitis barbae. Dr. Badreshia: Late-stage lesions, characterized by draining sinuses and large keloidal masses, are Dr. Badreshia: In severe cases, surgical excision or often refractory to treatment. I first try topical and carbon dioxide laser ablation followed by healing intralesional steroids in addition to topical and with secondary intention have been tried with oral antibiotics. I have not used retinoids but some success. I find excision with primary closure would consider them as an option to surgical to be an excellent surgical treatment modality for approaches. Early epilation is strongly encour- the management of extensive cases. Previous aged along with education. articles have reported that excision with second- intention healing is more effective than primary Dr. Vause: Intralesional triamcinolone with fluo- closure. Extremely large lesions should be excised rouracil for three consecutive months, followed by in multiple stages. Preoperatively, the surgeon serial excisions and postoperative immunotherapy must evaluate the size of the keloid, as well as the and/or radiation. laxity of nuchal skin, in determining whether the

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Acne keloidalis nuchae lesion should be excised in one, two, or even three Dr. Badreshia: I rule out any underlying or associ- stages. Complications may occur if the surgeon ated conditions through a history and physical excises a large keloid in one stage and subse- examination including the follicular occlusion quently attempts to close the resulting defect under triad (, suppurativa, excessive tension. Spread scars and restricted and pilonidal sinus). If there is drainage, cultures movement may be avoided if large keloids are are ordered. To calm down active inflammation excised in two stages, thus allowing the surgeon to and drainage, I prescribe oral antibiotics and pre- close the resulting defect without undue tension. dnisone. Isotretinoin, which can change the pattern of follicle keratinization and suppresses sebaceous Dr. Breadon: Patients with advanced keloidal gland activity, is prescribed at a dose of 1 mg/kg/ lesions require some form of surgical inter- day for at least 4 months after the disease is clini- vention. I haven’t detected a marked difference cally inactive. Concomitant therapies for resistant in the response of patients who undergo surgical lesions include intralesional steroid, incision and procedures with either scalpel excision (“cold drainage, and local excision. Laser treatment with steel”), carbon dioxide laser excision with the laser diode and Nd:YAG can be an excellent treatment beam in the focused mode, or carbon dioxide once active disease is controlled. laser vaporization in the defocused mode. If there is sufficient nuchal scalp laxity and the keloidal Dr. Vause: Culture. Start with a loading dose of oral plaque is small lying in a horizontal orientation, antibiotics tapering as symptoms improve. Long- excision with primary side-to-side closer is per- term maintenance therapy may be necessary. formed. If there is a broad area of scalp involve- Prescribe a steroid shampoo, solution and/or ment, I perform tangential shave excision of the perform intralesional injections. Instruct patients lesion(s), with healing by secondary intention. The to avoid occlusive pomade hair preparations and patient is treated with immediate postoperative excessive scalp manipulation. intralesional triamcinolone, 10 mg/cc to the surgical site(s), as well as monthly triamcinolone injections Dr. Brauner: I have fortunately seen it only very thereafter, ranging from 5 to 20 mg/cc strength, rarely but would culture the area and treat with typically for up to 6 months or longer in patients appropriate antibiotics followed by beginning who have undergone either type of surgical excision. with isotretinoin.

Questions on dissecting cellulitis and folliculitis Dr. Breadon: Early intervention and education is decalvans: essential. I start patients on high-dose oral zinc gluconate or sulfate, 220 mg three times daily with Question food, indefinitely. I often treat with minocycline, 100 mg twice daily. Daily scalp cleansing with What is your approach to treating patients with Phisohex can be helpful. Intralesional injections perifolliculitis capitis abscessens et suffodiens (dis- are administered at the time of the initial visit and secting cellulitis of the scalp)? monthly. Active, fluctuant lesions as well as scarred/ fibrotic lesions are injected with triamcinolone, in Response concentrations of 10-20-40 mg/cc, depending on the severity of the fibrosis. Very fibrotic lesions are Dr. Quarles: A 21-gauge needle and vacutainer excised and closed primarily. connected to a red-top test tube is a simple means of aspirating any seropurulent material within the Dr. Swinehart: Dissecting cellulitis and folliculitis abscess nonsurgically. Cultures are taken but are decalvans generally respond to broad-spectrum invariably negative as these abscesses are sterile. antibiotics or isotretinoin. In the rare case of bacterial growth, it is probably a result of previous rupture and becomes secondary Dr. Brody: I use sulfa and rifampin after obtain- infection. Intralesional triamcinolone 40 mg/cc is ing cultures in both dissecting cellulites and injected into the evacuated abscess and (1) pre- pseudofolliculitis. dnisone 60 mg initially tapered by 5 mg in the morning and (2) trimethoprim sulfide double- Question strength 20 mg bid for 10 days is prescribed. Maintenance therapy is tetracycline 500 mg twice How do you treat patients with folliculitis daily. decalvans?

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Response (generic) or minocycline. Discontinuance of greasy hair products is important. Dr. Quarles: Radiation can be helpful for this difficult problem. Summary Dr. Badreshia: Treatment is targeted to the etio- logies of : a primary bacterial Our experts feel that the first step in treating infection, Staphylococcus aureus, and retention patients with acne keloidalis nuchae is explaining of follicular products with secondary infection. As that the disease was not caused by the barber the chronic stage of this disease is characterized using unclean clippers to cut their hair. Patients by irreversible scarring and , it is impor- should be instructed to substitute tight, high- tant that effective treatment is started as soon as collared shirts with soft or no collared shirts when- possible. ever possible. Short haircuts and close scalp shaving Antibacterial soaps/, topical antibiotics, should be avoided. Daily shampooing with gently and topical and intralesional steroids should foaming benzoyl peroxide washes, chlorhexidine, be included in the regimien in addition to oral or mild keratolytic cleansers containing alpha antibiotics like tetracyclines following wound cul- hydroxy acids or tar are effective alternatives to tures. Alternative agents may include macrolides, standard shampoo products. Discontinuance of quinolones, and rifampin 300 mg twice daily hair greases and hair pomades is advised. and clindamycin 300 mg twice daily for 10 weeks. Early, mild papular disease responds to potent Rifampin and clindamycin are both lipophilic or super-potent topical steroids. Larger inflamed molecules and achieve good intracellular con- papulopustular lesions should be cultured and centrations within phagocytes, thus increasing the treated with topical antibiotics (after culture), potential for eradication of S. aureus. However, monthly intralesional triamcinolone (3–10 mg/cc) close laboratory monitoring for some of these anti- and an oral antibiotic such as a tetracycline or a biotics is mandatory. Oral zinc, presumably for its tetracycline-derivative minocycline, erythromycin, antiinflammatory effect, can also be helpful as an trimethoprim sulfamethoxazole, or rifampin. Isotre- adjunctive agent. I try to avoid steroids if there are tinoin can be considered for rapidly progressing no active lesions including papules, pustules, or disease. erythema. However, alternate-day systemic corti- Less keloidal nodules and plaques can be costeroid therapy has been reported to suppress shaved, followed by intralesional triamcinolone profound inflammation and reduce subsequent injections, injected with triamcinolone and scarring. Isotretinoin is well known for its effects on 5FU for three consecutive months, followed by the pilosebaceous unit and has documented success. serial excisions and postoperative radiation and/ Multiple surgical techniques have been imple- or immunotherapy or injected with 20 mg/cc mented with variable success in the treatment. triamcinolone. The disadvantage of surgical therapies is the When surgery remains the only option, carbon associated morbidity and unacceptable cosmetic dioxide laser debulkment and excision into the endpoints. CO2 laser has been used to excise fat, tangential shaving or primary excision with affected regions of the scalp followed by secondary secondary intention healing followed by radiation intention healing. Nd:YAG, diode, or long-pulsed therapy are alternatives. If primary closure is ruby laser has been reported to improve this folli- planned, preoperative assessment of nuchal laxity cular condition. is beneficial in determining whether serial excisions are indicated. Dr. Vause: One option is alternate intralesional All of our experts agree that obtaining a culture steroids with mesotherapy to affected areas. The is the first step in treating a patient with dissecting patients should discontinue all traumatic hair cellulitis of the scalp, although bacterial growth and scalp manipulations. Multivitamins and a hair may be the result of rupture and secondary fiber strength solution can be helpful. After 3–6 infection. Culture and aspiration can be completed months, we start surgical hair replacement. simultaneously by using a 21-gauge needle con- nected to a vacutainer and red-top tube. Following Dr. Brauner: Both of these diseases are very rare aspiration, intralesional triamcinolone 10–40 mg/ in my patient population. Betadine can be used as cc is administered in addition to oral antibiotics – a shampooing agent daily. After painting a culture, trimethoprim, tetracycline, minocycline, or rifampin – we consider prescribing erythromycin, Duricef is prescribed. Oral prednisone (60 mg tapered

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Acne keloidalis nuchae over 10 days) helps with the severe inflammation. References Once the active disease is controlled, oral zinc gluconate or sulfate 220 mg/day should be con- 1. Adegbidi H, Ogunbiyi A. Keloid acne of the neck: epidemio- sidered. Excision and diode and Nd:YAG laser may logical studies over 10 years. Int J Dermatol 2005: 44 can used is the lesions are fibrotic. (Suppl. 1): 49–50. 2. George A. Acne keloidalis in females: case report and review The mainstay of therapy for folliculitis decal- of literature. Indian J Dermatol Venereol Leprol 2005: 71: vans includes: antiseptic and steroid shampoos, 31–34. intralesional and oral steroids, and oral antibiotics. 3. Shah GK. Efficacy of diode laser for treating acne keloidalis Isotretinoin may be beneficial. nuchae. Indian J Dermatol Venereol Leprol 2005: 71: 31–34.

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