Acne Keloidalis Nuchae (AKN), also known as acne keloidalis, or folliculitis keloidalis, is a type of folliculitis (inflammation of the follicle) that can lead to scarring bumps and permanent alopecia. AKN primarily affects the posterior neck in men but can also occur in women. AKN occurs most commonly in African Americans and less commonly amongst Hispanics, Asians, and Caucasians.
AKN initially presents as itchy inflamed bumps (folliculitis) and pustules along the posterior lower hairline, or back of the scalp. These bumps can turn into firm keloid scars which will destroy the hair follicle. With a chronic course, the bumps can turn into thick keloid-like plaques with surrounding crust, drainage, and discomfort.
The cause for AKN is still being investigated; however, there is evidence that it is an inflammatory condition similar to acne. The lesions can start by trauma in the area. We are not sure if the trauma is a cut from a clipper, an ingrown hair, pulling hair too tight, or heat. Previous thoughts were the hairs were cut far below the skin surface and those curly hairs grew into the skin causing irritation that formed an ingrown hair bump. There was also the thought that barbers were not cleaning their equipment properly and introducing bacteria and other organisms into the scalp with the use of clippers. However, this condition can occur in women who do not shave their scalps or neck, and in individuals with straight hairs.
To tackle to the concept of dirty clippers, if this were an issue of contaminated clippers, then a pattern would be seen that all the individuals on that day would have been “infected” with the same clippers. In other words, if bacteria were on those clippers prior to cutting client #1″affected person”, then the bacteria were on the clippers for client #2, client #3, and so on. So everyone who had their hair cut that day would return with the same reaction on the scalp. Typically barbers will see a client with this condition but had they previously cut the client’s scalp then everyone coming back in would have the same complaint. This is not the case.
Early detection is important to prevent progression of the condition and salvage hairs. Treatment is aimed at reducing the amount of inflammation so the bumps smooth down and the hairs regrow. If the inflammation is longstanding, hair regrowth may not be possible. Treatments include intralesional steroid injections, oral anti-inflammatory medications, and topical steroid creams and solutions which can help with reducing the appearance and the symptoms of the affected area. Mild cases can be treated with topical benzoyl peroxide wash and acne medications. More advanced cases may still require systemic treatment in conjunction with surgical excision of areas. It is important to know when surgery is performed, hair cannot regrow into that area due to scar tissue. Additionally, new lesions may occur if the inflammatory process continues after surgery.
While close shaves are not a direct cause for the condition, I recommend patients to avoid irritation to the area during the acute treatment course (1-3 weeks). After that, I advise patients to make sure they do not feel discomfort or too much heat when getting their hair cut. If hair is not desired in the affected area, laser hair removal is an option to help with reducing triggers of inflammation. Close monitoring and follow-up is warranted to shut down any inflammation to halt the progression of the condition.