What is the recommended treatment for a patient with acne keloidalis nuchae?

Treatment of Acne Keloidalis Nuchae

For acne keloidalis nuchae, intralesional triamcinolone acetonide (10 mg/mL into inflammatory follicular lesions and 40 mg/mL into hypertrophic scars and keloids) is the recommended first-line medical therapy, with surgical excision reserved for refractory cases or advanced tumor-stage disease. 1

Initial Medical Management

Intralesional corticosteroid therapy is the cornerstone of medical treatment for AKN:

• Inject triamcinolone acetonide 10 mg/mL directly into inflammatory follicular lesions 1
• For established hypertrophic scars and keloids, use the higher concentration of triamcinolone acetonide 40 mg/mL 1
• Expect flattening of most lesions within 48-72 hours 1
• Critical caveat: Local overdose can result in atrophy, pigmentary changes, telangiectasias, and hypertrichosis, so use the minimum effective dose 1

Adjunctive medical therapies to consider:

• Topical and oral antibiotics may help control secondary infection and inflammation, though evidence is limited and recurrence is common 2, 3
• Medical management typically requires months of treatment with incomplete results 2

Surgical Management for Refractory or Advanced Disease

When intralesional steroids fail or disease is advanced (tumor-stage), surgical excision becomes necessary:

• Complete surgical excision down to deep subcutaneous tissue is the most effective modality, as complete removal of follicles leads to the least chance of local recurrence 4, 5
• For lesions <5 mm, punch excision followed by healing with secondary intention is effective 4
• For larger lesions, excision with primary closure provides the best cosmetic outcome when feasible 4
• For extensive tumor-stage disease: Deep excision followed by negative-pressure wound therapy (NPWT) for one week, then split-thickness skin graft with another week of NPWT achieves quicker healing compared to secondary intention 6

Laser Therapy as Alternative or Adjunctive Treatment

Light and laser therapies offer less invasive alternatives with strong evidence:

• The 1064-nm Nd:YAG laser, 810-nm diode laser, and CO2 laser demonstrate 82-95% improvement in 1-5 sessions with minimal side effects 2
• Long-pulsed Nd:YAG laser hair removal should be performed on the affected area and surrounding region to prevent new lesions from developing 4
• Side effects are minimal, with transient erythema and mild burning being most common 2

Treatment Algorithm Based on Disease Stage

Early inflammatory stage:

• Start with intralesional triamcinolone acetonide 10 mg/mL into inflammatory papules and pustules 1
• Add laser hair removal (1064-nm Nd:YAG) to prevent progression 4, 2

Established fibrotic plaques and small keloids:

• Intralesional triamcinolone acetonide 40 mg/mL into keloidal tissue 1
• Consider CO2 or Nd:YAG laser therapy for 82-95% improvement 2

Refractory lesions <5 mm:

• Punch excision with secondary intention healing 4
• Follow with laser hair removal to surrounding area 4

Advanced tumor-stage disease:

• Radical excision down to deep subcutaneous tissue 4, 5
• Primary closure if feasible, or staged reconstruction with NPWT and skin grafting for extensive lesions 6
• Mandatory laser hair removal to prevent recurrence 4

Critical Pitfalls to Avoid

• Never inject intralesional steroids at sites of active infection such as impetigo or herpes 1
• Avoid excessive steroid dosing, which causes permanent atrophy and pigmentary changes 1
• Do not rely solely on medical management for advanced tumor-stage disease, as months of treatment yield incomplete results with high recurrence rates 2
• Incomplete excision leads to recurrence—always excise down to deep subcutaneous tissue to remove all follicles 4
• Always combine surgical excision with laser hair removal of the surrounding area to prevent new lesion formation 4