Clinical Challenge: Firm Papules and Hair Loss


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A 29-year-old Black man presents with a history of painful breakouts affecting the back of his scalp and neck. The condition has been present for at least 1 year. He denies family history of a similar disorder; his younger brother is being treated for mild acne affecting his cheeks and forehead. Physical examination reveals multiple firm papules and pustules of the involved areas associated with hair loss.

Acne keloidalis nuchae or folliculitis keloidalis nuchae is a chronic inflammatory condition consisting of keloid-like papules and plaques that eventually manifest in scarring alopecia.1 It was first described by Kaposi in 1869 as dermatitis papillaris capillitia and was later coined acne...

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Acne keloidalis nuchae or folliculitis keloidalis nuchae is a chronic inflammatory condition consisting of keloid-like papules and plaques that eventually manifest in scarring alopecia.1 It was first described by Kaposi in 1869 as dermatitis papillaris capillitia and was later coined acne keloidalis nuchae.2,3 The name is misleading, however, as this is not a form of acne.4

A majority of cases arise in people of African descent and the disorder occurs infrequently in White patients.5,6 The condition is 20 times more common in men than women, suggesting that androgens may play a role in development.7 It rarely manifests before puberty or after middle age.

Acne keloidalis nuchae is induced by chronic inflammation or occlusion of the hair follicles. Injury to the skin and hair follicles as a result of hair cutting can lead to disease.8 Hair texture and propensity for ingrown hair allow for extrafollicular and transfollicular penetration of the skin favoring the development of acne keloidalis nuchae. An aberrant immune reaction resulting in chronic inflammation also plays a role in pathogenesis.9

Acne keloidalis nuchae is classified by the North American hair research society as a mixed form of primary cicatricial alopecia.10 Characteristic presentation is that of firm inflammatory papules and pustules on the occiput and/or nape of the neck that spread laterally.11 The onset of symptoms is preceded by pruritis several hours to days prior, commonly following irritation to the area. Coalescence and fibrosis of papules lead to formation of keloidal scarring plaques. Due to the pruritic nature, patients often scratch at the lesions causing inflammation and development of secondary bacterial infections. In some cases, recurrent folliculitis leads to development of patchy scarring alopecia.

The diagnosis is clinical although atypical cases may warrant culture. Dermatoscopic features of early lesions may show hair shafts trapped in individual papules.1 Biopsy is rarely indicated but may be done to exclude conditions such as psoriasis and folliculitis decalvans.12 Histopathology often reveals a neutrophilic and lymphocytic infiltrate surrounding the isthmus of the hair follicle and naked hair shafts in the dermis.13

Management of acne keloidalis nuchae is difficult. Medical treatment includes the use of topical or intralesional steroids, retinoids, and topical or oral antibiotics.4,11 A recent case report documented successful treatment with halobetasol and tazarotene.14 Surgical removal of refractory areas is another option.15

Patients should be advised to avoid close shaving and frequent haircuts. Providers should also educate patients about the use of antimicrobial cleansers, wearing loose clothing around the neck to prevent rubbing, and avoidance of pomades and hair grease.16

Alexandra Stroia, BS, is a medical student at the Lake Erie College of Osteopathic Medicine. Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.


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  2. Kaposi M. Ueber die sogennante Framboesia und mehrere andere arten von papillaeren neubildungen der Haut. Arch Dermatol Syphilol. 1869;3382-423.
  3. Fox H. Folliculits keloidalis a better term than dermatitis papillaris capillitii.  Arch Derm Syphilol. 1947;55(1):112. doi:10.1001/archderm.1947.01520010116015
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  10. Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American Hair Research Society (NAHRS)-sponsored workshop on cicatricial alopecia, Duke Medical Centre, February 10 and 11, 2001J Am Acad. 2003;48(1):103-110. doi:10.1067/mjd.2003.68
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