Clinical Challenge: Papules and Plaques of the Posterior Neck - MPR

Clinical Challenge: Papules and Plaques of the Posterior Neck

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A 24-year-old Hispanic man is referred for evaluation of a severe rash on his neck. His condition was first noted approximately 2 years ago and has recently increased in severity. He complains of intermittent tightness, pain, and drainage associated with the rash. His family history is negative for a similar condition. Examination reveals multiple firm papules and plaques on his posterior scalp and neck. Scattered acneiform papules are noted on his cheeks.

Acne keloidalis nuchae (AKN) begins as papules and pustules that develop into firm crusted plaques.1 Despite its name, AKN is not a keloid.2 The posterior scalp and neck are the primary sites of involvement, and the condition is almost exclusively found in...

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Acne keloidalis nuchae (AKN) begins as papules and pustules that develop into firm crusted plaques.1 Despite its name, AKN is not a keloid.2 The posterior scalp and neck are the primary sites of involvement, and the condition is almost exclusively found in Black teenagers and young adults.1,2 Hereditary predisposition and the combination of coarse curly hair and chronic irritation play prominent roles in pathogenesis.1,2

In a study, AKN was more common among Black athletes who wore helmets (ie, football players).3 In another study, AKN was also common in Black individuals who had frequent haircuts.4 Complications of AKN include abscess formation, chronic drainage, and scarring alopecia that may progress into permanent hair loss.2

Treatment of AKN is challenging; to date no regimen has proven universally successful. Affected individuals should avoid tight-fitting collars, frequent haircuts, and close shaving. The early stage of the disease may respond to topical steroids and retinoids as well as topical and oral antibiotics.2 Intralesional injection of triamcinolone may flatten existing lesions and minimize fibrosis. Low-dose oral isotretinoin has been used on a chronic basis with varying degrees of control. Several studies document improvement following laser ablation; advanced disease often warrants excision of refractory and painful areas.1,2

Greg Forsyth, PA-C, is a physician assistant at the DermDox Center for Dermatology in Camp Hill and Mechanicsburg, PA. Stephen Schleicher, MD, is director of the DermDox Center for Dermatology in Pennsylvania, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.                                                         

References

1. Dinehart SM, Herzberg AJ, Kerns BJ, Pollack SV. Acne keloidalis: a reviewJ Dermatol Surg Oncol. 1989;15(6):642-647.  

2. Ogunbiyi A. Acne keloidalis nuchae: prevalence, impact, and management challengesClin Cosmet Investig Dermatol. 2016;9:483-489.

3. Knable AL Jr, Hanke CW, Gonin R. Prevalence of acne keloidalis nuchaein football players. J Am Acad Dermatol. 1997;37(4):570-574.

4. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adultsBr J Dermatol. 2007;157(5):981-988.