Occipital scalp papules in a teenage boy

Treat with steroids, antibiotics

Treatment of acne keloidalis nuchae is often difficult. Early treatment, however, decreases the potential for developing larger lesions and long-term disfigurement.¹

Acne keloidalis nuchae is often improved with a combination of topical or intralesional steroids, topical tretinoin, and systemic antibiotics. Topical steroid therapy is indicated for mild to moderate acne keloidalis nuchae. Application of tretinoin 0.01% gel once or twice daily for several months has an anti-inflammatory effect and alters keratinocyte differentiation, which may discharge ingrown hairs. Topical and systemic antibiotics minimize infection associated with pseudofolliculitis and have anti-inflammatory effects.^1,3 Intralesional steroid injections (triamcinolone acetonide 2.5-5 mg/cc) with 0.1 cc injected into each lesion every 2 to 3 weeks for 3 to 6 injections can reduce inflammation and pruritus and reduce the thickness of keloidal scars.³ (For a how-to video that illustrates intralesional injections, go to http://www.jfponline.com/multimedia/video.html.)

Surgical management is generally reserved for large lesions that do not respond to medical management. Surgical excision with healing by secondary intention has been reported to cause fewer recurrences than surgical excision with primary closure.⁴ The use of CO₂ laser ablation can be considered for advanced cases.⁵

Teach patients with acne keloidalis nuchae that they can prevent further irritation of the affected area by not wearing head gear that rubs on the involved area. Patients should also refrain from shaving the posterior scalp and neck to prevent the pseudofolliculitis that may be causing this condition.^1,3 Electric barber trimmers that leave a short stubble but do not cleanly shave the skin are OK to use.

Our patient’s papules flattened and became asymptomatic over several months of treatment with tretinoin 0.01% gel, doxycycline 100 mg daily, and a series of biweekly intralesion steroid injections. A flat-scarred patch remained.

CORRESPONDENCE
Robert T. Brodell, MD, Division of Dermatology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216; rbrodell@umc.edu