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.
I have patients that commonly present to clinic for ingrown hairs in the beard, on the scalp, and all body sites subjected to shaving. Certain individuals are more prone to ingrown bumps. The development of these bumps are two-fold.
First, the structure of the hair increases the risk of developing ingrown bumps. The curliness of a hair depends on the number of disulfide bonds (these are the bonds broken or created with chemical process such as relaxers and perms, respectively). The higher the number of bonds the curler the hair. African Americans have a high number of disulfide bonds hence tight curls when the hair is in its natural state and hence are at a higher risk of developing ingrown hairs.
Second, when the hair is cut below the skin surface, which occurs with clean shaves, the hair is cut at a sharp angle. When the hair regrows, it curls into the skin and causes inflammation. This inflammation can start with a small red bump which is commonly known as an ingrown hair bump. Over time, the hair may grow out of the skin but may cause residual scar tissue, discoloration of the skin (red or dark marks), and possibly a keloid, a type of thick scar.
A lot of the treatments are aimed at prevention. Following these simple steps can help prevent ingrown hairs in the future:
- Try trimming with clippers instead of razor blades. This will prevent the hairs from being cut below the skin surface and therefore prevent ingrown hairs. If you desire the smooth shave appearance and want a permanent fix consider laser hair removal.
- Use a gentle exfoliant daily to remove dirt and debris which can clog pores and further cause ingrown hairs.
- Wash area at least daily and use a warm towel to perform a steam treatment to further open the pores. I tell patients to do this especially prior to a shave. This will moisten skin and help prevent razor burns.
- Use a shaving foam without too much slip ( not too slippery) so you don’t slide over hairs and miss them while shaving. This will prevent you from having to make multiple passes over one area and prevent irritation of the skin which can cause swelling and shrinkage of the pores and therefore cover hairs below the surface of the skin.
- A common habit is to dig into the skin and remove the trapped ingrown hair. This is a last resort and I strongly discourage this as it can leave pock-mark or icepick-like scars and discolor the skin from injury.
- Try using a tea tree oil cleanser or moisturizer which has antibacterial properties.
Some individuals may be prone to acne-like lesions in hair-barren areas. These individuals will require oral or topical prescription medications. If the above steps do not help, contact your local dermatologist to find a treatment regimen that will work for you. Share any remedies that may have worked for you.