What is the treatment for Acne Keloidalis Nuchae?

Treatment of Acne Keloidalis Nuchae

For early-stage Acne Keloidalis Nuchae (AKN), initiate intralesional triamcinolone acetonide injections (10 mg/mL into inflammatory follicular lesions, 40 mg/mL into hypertrophic scars and keloids) combined with laser hair removal using long-pulsed Nd:YAG laser to prevent new lesion formation; for advanced refractory disease, surgical excision remains the definitive treatment with the highest success rates. 1, 2, 3

Understanding AKN and Treatment Goals

• AKN is a chronic scarring folliculitis affecting the occipital scalp and nape of the neck, characterized by inflammatory papules, pustules, and keloidal plaques that lead to permanent alopecia 4
• The condition predominantly affects post-pubertal men of African descent and is not a true keloid despite its name 4
• Treatment goals include reducing inflammation, preventing new lesion formation by eliminating hair follicles, and removing existing fibrotic masses 2, 3

Early-Stage Disease: Medical Management

Intralesional Corticosteroids (First-Line)

• Inject triamcinolone acetonide at 10 mg/mL concentration directly into inflammatory follicular lesions 1
• For established hypertrophic scars and keloids, use triamcinolone acetonide at 40 mg/mL concentration 1
• Intralesional steroids flatten most lesions within 48-72 hours and are efficacious for occasional or stubborn lesions 1
• This approach is NOT effective as a standalone strategy for patients with multiple extensive lesions 1

Laser Hair Removal (Essential Adjunct)

• Long-pulsed Nd:YAG laser (1064-nm) is the most studied and effective modality for preventing new lesion formation 2, 3
• Apply laser hair removal to the entire affected area and surrounding regions to eliminate follicles and prevent recurrence 2
• The 1064-nm Nd:YAG laser and 810-nm diode laser achieve 82-95% improvement in 1-5 sessions with minimal side effects (transient erythema and mild burning) 3
• Complete follicle removal leads to the lowest chance of local recurrence 2

Advanced or Refractory Disease: Surgical Approaches

Lesion Size-Based Algorithm

• For lesions <5 mm: Perform punch excision followed by healing with secondary intention 2
• For larger discrete lesions (5-20 mm): Perform complete surgical excision with primary closure 2
• For extensive confluent masses where primary closure is not feasible: Use intralesional cryotherapy 2
• For very extensive disease: Consider staged reconstruction with deep excision down to subcutaneous tissue, negative-pressure wound therapy for one week, followed by split-thickness skin graft and another week of negative-pressure wound therapy 5

Combined CO2 Laser Ablation Approach

• CO2 laser ablation followed immediately by intralesional triamcinolone injection in the same session offers excellent results with minimal downtime 6
• This outpatient procedure shows good results with no relapse and less recovery time compared to traditional surgical excision 6
• CO2 laser allows for 82-95% improvement with minimal side effects 3

Multimodality Treatment Protocol

• Always combine surgical or ablative treatment with long-pulsed Nd:YAG laser hair removal of the surrounding area to prevent new lesions 2
• Patients treated with this combined approach show 80-90% overall reduction in lesions with satisfactory cosmetic outcomes 2
• 100% patient satisfaction was achieved with multimodality surgical approaches tailored to lesion morphology 2

Critical Pitfalls to Avoid

• Do not rely solely on intralesional steroids for multiple or extensive lesions, as this approach is inadequate and delays definitive treatment 1
• Avoid incomplete excision, as partial removal of follicles leads to high recurrence rates 2
• Do not neglect laser hair removal of surrounding areas, as residual follicles will generate new lesions 2
• Traditional medical management with oral/topical antibiotics and topical steroids requires months of treatment with incomplete results and common recurrences 3
• Patients may attempt self-treatment with corrosives, acids, or car engine oils, leading to larger lesions and unsightly scars 4

Treatment Selection Based on Disease Stage

• Early papular stage: Intralesional triamcinolone (10 mg/mL) + Nd:YAG laser hair removal 1, 2, 3
• Established keloidal plaques: Intralesional triamcinolone (40 mg/mL) + Nd:YAG laser hair removal, or CO2 laser ablation with immediate intralesional steroid injection 1, 6
• Refractory disease with small lesions (<5 mm): Punch excision + Nd:YAG laser hair removal 2
• Refractory disease with larger lesions: Complete surgical excision with primary closure + Nd:YAG laser hair removal 2
• Extensive confluent masses: Intralesional cryotherapy or staged reconstruction with skin grafting + Nd:YAG laser hair removal 2, 5