The FP diagnosed acne keloidalis nuchae (AKN), a condition that occurs most often in black men, but can be seen in all ethnic groups. The lesions are often painful and cosmetically disfiguring. The exact cause of AKN is uncertain, but it often develops in areas of pseudofolliculitis or folliculitis. It may be associated with haircuts where the posterior hairline is shaved with a razor and in individuals with tightly curled hair shafts. Other possible etiologies include irritation from shirt collars and a chronic bacterial infection.
Tretinoin cream 0.025% may be useful in patients with a mild case of the disease, but it is rarely helpful in moderate to severe cases. It is first applied nightly for a week, and then reduced to every second or third night. Tretinoin may be used in conjunction with a mid-potency topical corticosteroid that is applied each morning.
In this case, the FP recommended that the patient avoid using a razor on the back of his neck and that he allow his hair to grow a bit longer there. This would minimize the irritation and also cover up some of the visible lesions. The FP also prescribed a 2-week course of doxycycline 100 mg bid and topical tretinoin 0.025% cream in the evening, with triamcinolone 0.1% cream in the morning to help with the itching and inflammation.
The patient returned a month later with fewer symptoms and lesions. The FP explained that there are no curative treatments and that he should stick with the current topical treatments for a bit longer.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Pseudofolliculitis and acne keloidalis nuchae. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:665-670.
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