What is the diagnosis and recommended management for a teenage African‑American male who presents with pruritic papules and pustules on the posterior neck after shaving?

Folliculitis Keloidalis Nuchae (Acne Keloidalis Nuchae)

Diagnosis

This teenage African-American male presenting with pruritic papules and pustules on the posterior neck after shaving has folliculitis keloidalis nuchae (FKN), a chronic scarring folliculitis that predominantly affects men of African descent in the post-pubertal period. 1

Clinical Features to Confirm Diagnosis

• Follicular papules and pustules that can coalesce into firm hypertrophic plaques and nodules specifically on the nape of the neck 2
• Pruritus is the most common symptom (reported in 71.1% of cases), though pain (9.6%) and bleeding during haircuts (1.2%) may also occur 3
• The condition occurs almost exclusively in post-pubertal males of African descent and is rare after age 55 1
• Despite the name, FKN is not a true keloid, and affected individuals do not have increased tendency to develop keloids elsewhere 1

Key Etiologic Factor in This Case

• Trauma from shaving (particularly electric razors) is the most commonly identified trigger in Nigerian studies, accounting for the majority of cases 4
• Other contributing factors include androgens, inflammation, ingrowing hairs, and secondary infection 1, 3

---

Management Algorithm

Step 1: Immediate Behavioral Modifications

• Stop sharing shaving instruments immediately - shared barber instruments pose risk of blood-borne infection transmission, especially with active bleeding lesions 1, 3
• Minimize mechanical trauma to the posterior neck during haircuts 4
• Consider avoiding close shaving or switching to less traumatic hair removal methods 5
• Personalize haircare instruments to prevent cross-contamination 4

Step 2: Initial Medical Management for Active Lesions

For papules and pustules without significant scarring:

• Apply clindamycin phosphate 1% solution or gel twice daily to affected areas for up to 12 weeks 6
• Use gentle pH-neutral soaps with tepid water, pat skin dry, and wear loose-fitting cotton clothing 6
• Avoid greasy creams in affected areas during active infection 6

If systemic signs present (fever >38°C, tachycardia >90 bpm, or extensive cellulitis):

• Add systemic antibiotics with MRSA coverage given the patient population and potential for secondary infection 7, 6
• Obtain Gram stain and culture if presentation is atypical or not responding to empirical therapy 6

Step 3: Management of Recurrent Disease

Implement decolonization protocol:

• Apply mupirocin ointment twice daily to anterior nares for the first 5 days of each month for long-term suppression (reduces recurrences by approximately 50%) 7, 6
• Daily chlorhexidine body washes and decontamination of personal items 7, 6
• Consider oral clindamycin 150 mg once daily for 3 months, which decreases subsequent infections by approximately 80% 6

Step 4: Surgical Management for Advanced Disease

For firm hypertrophic plaques and nodules:

• Surgical excision with secondary intention healing is the definitive treatment for established keloidal lesions 2
• This approach results in good cosmesis with little or no recurrence 2
• Alternative surgical options include excision with primary closure or skin grafting, though secondary intention healing is preferred 2

---

Critical Pitfalls to Avoid

• Do not use topical acne medications without dermatologist supervision as they may irritate and worsen folliculitis 6
• Avoid prolonged topical steroid use as this can cause skin atrophy and perioral dermatitis 6
• Do not apply caustic substances (engine oil, acids, corrosives) - these lead to larger lesions and unsightly scars, yet are commonly used in some communities 1, 3
• Do not prescribe systemic antibiotics for simple folliculitis without systemic signs, as this promotes antibiotic resistance without improving outcomes 7
• Warn patients about blood-borne infection risk from shared shaving instruments, especially when active lesions are bleeding 1, 3

---

Treatment Expectations

• Early intervention prevents progression to unsightly keloidal masses that significantly impact quality of life 1
• The presence of keloidal lesions is more stressful to patients than the resulting alopecia 1
• Treatment is often disappointing with topical steroids/antibiotics and oral antibiotics alone in established disease 2
• Surgical excision becomes necessary when medical management fails or disease is advanced 2