Acne keloidalis nuchae (AKN) is a frustrating dermatologic condition that is often as vexing for patients as it is challenging to manage for their consulting dermatologists. AKN presents with pustules and papules that may coalesce into larger keloid-like nodules located on the posterior concavity of the neck near the collar line.
A factor common to most AKN patients is the presence of coarse curly hair in this area.1 Higher testosterone levels have also been speculated to play a role.1 Black males are most often affected, although AKN has been noted less commonly in Asian, Hispanic and Caucasian patients.1-4 The condition occurs following adolescence with the vast majority of those affected being under age 40.5 Only rarely have women been reported to suffer from AKN.6,7
Other factors that may contribute include close shaving or clipping of hair and mechanical friction from collars or helmets.8,9 It has been described uncommonly in association with the use of medications, such as cyclosporine, and certain anti-epileptic drugs.3,10
In this article, we offer a brief overview of treatment options and report on a 39-year-old African American male with AKN treated with electrosurgical excision. This patient’s excision was followed by the topical application of a hemostatic agent and secondary intention healing.
Therapeutic Alternatives
Conservative treatments for AKN have included refraining from shaving or close trimming of hair in the affected area. Avoidance of mechanical occlusion from helmets or repetitive rubbing from shirt collars also appears to be of benefit. Topical antibacterial products containing benzoyl peroxide, erythromycin or clindamycin may also be therapeutic. However, if the skin is noted to be frankly infected, oral antibiotics should be considered in the short-term. If cultures are conducted, empiric antibiotics can be tailored to bacterial sensitivity results when they become available. Once mild disease has stabilized, it is often controlled with topical corticosteroids and possibly retinoids as well.11
Laser hair removal (LHR) can be specifically therapeutic and may be preventive early in the course of AKN. Often the major limitation is the effective use of LHR in darker skin types. Success has been reported, however, particularly with the longer wavelength 810 nm diode and 1064 nm NdYAG laser platforms.12,13 Carbon dioxide laser ablation has also been reported, but may be restricted by its limited ability to control brisk bleeding as well as prolonged post-operative healing times and relatively high recurrence rates.14
Intralesional triamcinolone acetonide injections are often first-line therapy once keloid-like papules and nodules appear.15 Cryotherapy can also be effective, but its use may be limited by concerns regarding post-treatment hypopigmentation, which can be particularly evident in darker Fitzpatrick skin types.15
Electrodesiccation under local anesthetic can debulk smaller lesions and may be less likely to result in hypopigmentation.16 As with the treatment of traditional keloid scars, local radiotherapy has also been employed for AKN.16 Patients treated with radiation may benefit from the permanent epilation sometimes associated with this therapy. Unfortunately, radiotherapy can also be accompanied by unwelcome post-radiation skin changes and the long-term carcinogenic risks associated with all ionizing radiation.16,17 As a result, its use in the treatment of AKN has fallen out of favor in recent years.
Surgical excision of AKN is generally reserved for refractory cases associated with a significant burden of keloid-like scar. Though smaller lesions may be removed with more basic techniques such as punch biopsy, larger lesions often require ellipse excision. Moderate post-operative defects may be closed primarily, but if more extensive skin deficits exist alternate approaches such as the use of tissue expanders have been employed.18 Skin grafting has also been utilized, but cosmetic outcomes are generally considered to be less favorable with this option.19 Finally, secondary intention healing is a practical alternative commonly employed for larger wounds though patients must be willing to commit to a prolonged course of wound care (as long as 6-12 weeks).
Case Report: Excision via Electrosurgery
Our patient presented with several fairly large scar-like nodules on the posterior aspect of his neck (Figure 1). He described that the lesions had enlarged progressively over the last few years despite numerous treatments with intralesional triamcinolone. The patient had become increasingly dissatisfied with these more conservative treatments and was interested in pursuing a surgical solution.
Figure 1. Pre-operative: Acne keloidalis nuchae with keloid-like scars.
Elective surgical excision was conducted following local infiltration of lidocaine with epinephrine. The keloid-like nodules were outlined with surgical marker incorporating a 3-mm to 4-mm margin. Though it is generally recommended that a single horizontal ellipse be conducted to include the posterior hairline, given the geometry and superior location of the lesions in this patient, we determined that a customized approach was more appropriate in this case.20
Consequently, we elected to proceed with 2 separate horizontal ellipses placed narrowly above the hairline. The lesions were excised with electrosection utilizing an Ellman Surgitron (Ellman International Inc; Hicksville, NY) in biterminal “cut/coag” mode (rectified, non-filtered) with a fine needle electrode. Electrosection in mixed “cut/coag” mode allowed for a clean incision with minimal tissue resistance. This mode simultaneously helped to provide management of concomitant bleeding on the highly vascular posterior scalp. To ensure that the excision was entirely sub-follicular, the tissue was incised down to the level of deep subcutaneous fat. Any bleeding points that remained were readily managed with additional focal electrocoagulation. The 2 open wounds that resulted were left to heal by secondary intention.
To help limit oozing and reduce the possibility of subsequent post-operative hemorrhage, we elected to apply WoundSeal (Biolife, LLC; Sarasota, FL) to the lesions following excision (Figure 2).
Figure 2. Intraoperative: Post-electrosection with hemostatic agent.
This hydrophilic powder is reported to dehydrate blood on contact.21 The powder contains an ion exchange resin including potassium ferrate, which instigates the agglutination of blood cells forming a hemostatic and occlusive seal. Though the literature accompanying WoundSeal recommends its use in wounds with a depth of 1 mm or less, the product has been reported to be beneficial in deeper wounds left to heal secondarily.21,22 The product’s reaction with blood is mildly exothermic. While some warming of the wound was evident following its application, in our patient no untoward effects were noted.
Traditional non-adhesive wound dressings were subsequently applied and our patient was discharged home. No prophylactic antibiotics were prescribed. Wound care instructions included twice daily, warm water soaks followed by the application of mupirocin ointment beneath a fresh dressing. These soaks eventually flushed away the residual hemostatic powder as well as any persistent serous crust.
Discussion
Cold-steel excision is challenging due to often brisk bleeding associated with scalp incision. Pure electrosection alone provides little if any advantage in this regard, but if settings are combined with damped coagulation waveforms — this is of benefit in providing both a precise incision while simultaneously helping to control bleeding along the wound edges.
While wound tension after traditional primary closure can be associated with early post-operative restrictions to neck flexion or even result in baseline neck extension, these issues are circumvented with secondary intention healing (SIH).20,23 Concerns regarding wound dehiscence, which may complicate sutured closures, are also avoided with SIH. Post-operative pain, however, has been reported in some studies to be greater in wounds that were left open to heal versus those closed primarily with sutures.20,24 In patients managed with SIH, the possible need for oral analgesics should be anticipated in the first few days following surgery.
Scar widening has also been reported as a late complication after primary closure following AKN excision.24 This is not unexpected as these wounds are often under considerable tension on closure. Undoubtedly this level of tension is only aggravated by the strain associated with the remarkable mobility inherent to this region. Somewhat surprisingly, wounds left open for SIH on the posterior neck undergo significant post-operative contraction and once healed their appearance often rivals that of wounds closed primarily with sutures. Remarkably, recurrence rates following AKN excision have also been reported to be higher with primary closure than in wounds that are allowed to heal by secondary intention.25
Patient Outcome
Our patient denied any need for analgesics after his excision. This is contrary to a previously reported series that noted 4 of 4 AKN patients treated with electrosurgery and SIH required narcotic analgesics for pain control.24 We speculate that the hemostatic agent utilized for our patient to seal the wound and prevent hemorrhage may also have been associated with reduced early post-operative discomfort.
Our patient noted his wounds were fully healed 8 weeks following the procedure. Digital photos were captured at 12 weeks (Figure 3). The 2 large excision sites allowed to heal by secondary intention had contracted considerably in size and at 12 weeks were rated as “very acceptable” by the patient. Our close inspection did reveal a small amount of mildly hypertrophic scar on the right, but failed to show any further evidence of active AKN related inflammation or recurrent keloid-like scar. The patient remained recurrence free at 4 months follow-up.
Figure 3. Post-operative (12 weeks): Secondary healing with wound contraction.
In summary, though AKN can be vexing for patients — effective treatments are available. Electrosurgical excision in our patient appeared to provide a very satisfactory outcome and this has been confirmed in similar reports describing AKN excision followed by second intention healing.20,25 The use of a potassium ferrate containing polymer as a hemostatic agent in this case appeared to be well-tolerated and may be advantageous post-operatively in both limiting oozing and preventing subsequent bleeding. In our patient, post-operative discomfort also appeared to be diminished. Further investigation is warranted to confirm the post-operative utility of this hemostatic agent and its safety in deeper wounds left to heal secondarily.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Lortie is a procedural dermatology Mohs surgery fellow at Affiliated Dermatologists in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist and the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. George AO, Akanji, AO, Nduka EU, Olasode JB, Odusan O. Clinical, biochemical and morphologic features of acne keloidalis in a black population. Int J Dermatol. 1993;32(10):714-716.
2. Salami T, Omeife H, Samuel S. Prevalence of acne keloidalis nuchae in Nigerians. Int J Dermatol. 2007;46(5):482-484.
3. Azurdia RM, Graham RM, Weismann K, Guerin DM. Acne keloidalis in caucasian patients on cyclosporin following organ transplantation. Br J Dermatol. 2000;143(2):465-467.
4. Bajaj V, Langtry JA. Surgical excision of acne keloidalis nuchae with secondary intention healing. Clin Exp Dermatol. 2007;33(1):53-55.
5. Adegbidi H, Atadokpede F, do Ango-Padonou F, Yedomon H. Keloid acne of the neck: epidemiological studies over 10 years. Int J Dermatol. 2005;44(suppl 1):49-50.
6. Ogunbiyi A, George A. Acne keloidalis in females: case report and review of literature. J Natl Med Assoc. 2005;97(5):736-738.
7. Dinehart SM, Tanner L, Mallory SB, Herzberg AJ. Acne keloidalis in women. Cutis 1989;44(3):250-252.
8. Knable AL Jr, Hanke CW, Gonin R. Prevalence of acne football players. J Am Acad Dermatol. 1997;37(4):570-574.
9. Harris H. Acne keloidalis aggravated by football helmets. Cutis. 1992;50(2):154.
10. Grunwald MH, Ben-Dor D, Livni E, Halevy S. Acne keloidalis-like lesions on the scalp associated with antiepileptic drugs. Int J Dermatol. 1990;29(8):559-561.
11. Callender VD, Young CM, Haverstiock CL, Carroll CL, Feldman SR. An open label study of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of mild to moderate acne keloidalis. Cutis. 2005;75(6):317-321.
12. Shah GK. Efficacy of diode laser for treating acne keloidalis nuchae. Indian J Dermatol Venereol Leprol. 2005;71(1):31-34.
13. Esmat SM, Abdel Hay RM, Abu Zeid OM, Hosni HN. The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study. Eur J Dermatol. 2012;22(5):645-650.
14. Kantor GR, Ratz JL, Wheeland RG. Treatment of acne keloidalis nuchae with carbon dioxide laser. J Am Acad Dermatol. 1986;14(2 Pt 1):263-267.
15. Layton AM, Yip J, Cunliffe WJ. A comparison of intralesional triamcinolone and cryosurgery in the treatment of acne keloids. Br J Dermatol. 1994;130(4):498-501.
16. Bard C, Wolff M. Acne keloidalis. Plast Reconstr Surg. 1972;50(1):25-30.
17. Sidle DM, Kim H. Keloids: prevention and management. Facial Plast Surg Clin North Am. 2011;19(3):505-515.
18. Pestalardo CM, Cordero A Jr, Ansorena JM, Bestue M, Martinho A. Acne keloidalis nuchae. Tissue expansion treatment. Dermatol Surg. 1995;21(8):723-724.
19. Malherbe F. Sycosis nuchae and its surgical treatment. Plast Reconstr Surg. 1971;47(3):269-271.
20. Glenn MJ, Bennett RG, Kelly AP. Acne keloidalis nuchae: treatrnent with excision and second-intention healing. J Am Acad Dermatol. 1995;33 (2 Pt 1):243-246.
21. Biolife, LLC. Urgent QR product information. https://www.biolife.com. Accessed March 20, 2014.
22. Ho J, Hruza G. Hydrophilic polymers with potassium salt and microporous polysaccharides for use as hemostatic agents. Dermatol Surg. 2007;33(12):1430-1433.
23. Dinehart SM, Herzberg AJ, Kerns BL, Pollack SV. Acne keloidalis: a review. J Dermatol Surg Oncol. 1989;15(6):642-647.
24. Gloster HM Jr. The surgical management of extensive cases of acne keloidalis nuchae. Arch Dermatol. 2000;136(11):1376-1379.
25. Califano J, Miller S, Frodel J. Treatment of occipital acne keloidalis by excision followed by secondary intention healing. Arch Facial Plast Surg. 1999;1(4):308-311.
Acne keloidalis nuchae (AKN) is a frustrating dermatologic condition that is often as vexing for patients as it is challenging to manage for their consulting dermatologists. AKN presents with pustules and papules that may coalesce into larger keloid-like nodules located on the posterior concavity of the neck near the collar line.
A factor common to most AKN patients is the presence of coarse curly hair in this area.1 Higher testosterone levels have also been speculated to play a role.1 Black males are most often affected, although AKN has been noted less commonly in Asian, Hispanic and Caucasian patients.1-4 The condition occurs following adolescence with the vast majority of those affected being under age 40.5 Only rarely have women been reported to suffer from AKN.6,7
Other factors that may contribute include close shaving or clipping of hair and mechanical friction from collars or helmets.8,9 It has been described uncommonly in association with the use of medications, such as cyclosporine, and certain anti-epileptic drugs.3,10
In this article, we offer a brief overview of treatment options and report on a 39-year-old African American male with AKN treated with electrosurgical excision. This patient’s excision was followed by the topical application of a hemostatic agent and secondary intention healing.
Therapeutic Alternatives
Conservative treatments for AKN have included refraining from shaving or close trimming of hair in the affected area. Avoidance of mechanical occlusion from helmets or repetitive rubbing from shirt collars also appears to be of benefit. Topical antibacterial products containing benzoyl peroxide, erythromycin or clindamycin may also be therapeutic. However, if the skin is noted to be frankly infected, oral antibiotics should be considered in the short-term. If cultures are conducted, empiric antibiotics can be tailored to bacterial sensitivity results when they become available. Once mild disease has stabilized, it is often controlled with topical corticosteroids and possibly retinoids as well.11
Laser hair removal (LHR) can be specifically therapeutic and may be preventive early in the course of AKN. Often the major limitation is the effective use of LHR in darker skin types. Success has been reported, however, particularly with the longer wavelength 810 nm diode and 1064 nm NdYAG laser platforms.12,13 Carbon dioxide laser ablation has also been reported, but may be restricted by its limited ability to control brisk bleeding as well as prolonged post-operative healing times and relatively high recurrence rates.14
Intralesional triamcinolone acetonide injections are often first-line therapy once keloid-like papules and nodules appear.15 Cryotherapy can also be effective, but its use may be limited by concerns regarding post-treatment hypopigmentation, which can be particularly evident in darker Fitzpatrick skin types.15
Electrodesiccation under local anesthetic can debulk smaller lesions and may be less likely to result in hypopigmentation.16 As with the treatment of traditional keloid scars, local radiotherapy has also been employed for AKN.16 Patients treated with radiation may benefit from the permanent epilation sometimes associated with this therapy. Unfortunately, radiotherapy can also be accompanied by unwelcome post-radiation skin changes and the long-term carcinogenic risks associated with all ionizing radiation.16,17 As a result, its use in the treatment of AKN has fallen out of favor in recent years.
Surgical excision of AKN is generally reserved for refractory cases associated with a significant burden of keloid-like scar. Though smaller lesions may be removed with more basic techniques such as punch biopsy, larger lesions often require ellipse excision. Moderate post-operative defects may be closed primarily, but if more extensive skin deficits exist alternate approaches such as the use of tissue expanders have been employed.18 Skin grafting has also been utilized, but cosmetic outcomes are generally considered to be less favorable with this option.19 Finally, secondary intention healing is a practical alternative commonly employed for larger wounds though patients must be willing to commit to a prolonged course of wound care (as long as 6-12 weeks).
Case Report: Excision via Electrosurgery
Our patient presented with several fairly large scar-like nodules on the posterior aspect of his neck (Figure 1). He described that the lesions had enlarged progressively over the last few years despite numerous treatments with intralesional triamcinolone. The patient had become increasingly dissatisfied with these more conservative treatments and was interested in pursuing a surgical solution.
Figure 1. Pre-operative: Acne keloidalis nuchae with keloid-like scars.
Elective surgical excision was conducted following local infiltration of lidocaine with epinephrine. The keloid-like nodules were outlined with surgical marker incorporating a 3-mm to 4-mm margin. Though it is generally recommended that a single horizontal ellipse be conducted to include the posterior hairline, given the geometry and superior location of the lesions in this patient, we determined that a customized approach was more appropriate in this case.20
Consequently, we elected to proceed with 2 separate horizontal ellipses placed narrowly above the hairline. The lesions were excised with electrosection utilizing an Ellman Surgitron (Ellman International Inc; Hicksville, NY) in biterminal “cut/coag” mode (rectified, non-filtered) with a fine needle electrode. Electrosection in mixed “cut/coag” mode allowed for a clean incision with minimal tissue resistance. This mode simultaneously helped to provide management of concomitant bleeding on the highly vascular posterior scalp. To ensure that the excision was entirely sub-follicular, the tissue was incised down to the level of deep subcutaneous fat. Any bleeding points that remained were readily managed with additional focal electrocoagulation. The 2 open wounds that resulted were left to heal by secondary intention.
To help limit oozing and reduce the possibility of subsequent post-operative hemorrhage, we elected to apply WoundSeal (Biolife, LLC; Sarasota, FL) to the lesions following excision (Figure 2).
Figure 2. Intraoperative: Post-electrosection with hemostatic agent.
This hydrophilic powder is reported to dehydrate blood on contact.21 The powder contains an ion exchange resin including potassium ferrate, which instigates the agglutination of blood cells forming a hemostatic and occlusive seal. Though the literature accompanying WoundSeal recommends its use in wounds with a depth of 1 mm or less, the product has been reported to be beneficial in deeper wounds left to heal secondarily.21,22 The product’s reaction with blood is mildly exothermic. While some warming of the wound was evident following its application, in our patient no untoward effects were noted.
Traditional non-adhesive wound dressings were subsequently applied and our patient was discharged home. No prophylactic antibiotics were prescribed. Wound care instructions included twice daily, warm water soaks followed by the application of mupirocin ointment beneath a fresh dressing. These soaks eventually flushed away the residual hemostatic powder as well as any persistent serous crust.
Discussion
Cold-steel excision is challenging due to often brisk bleeding associated with scalp incision. Pure electrosection alone provides little if any advantage in this regard, but if settings are combined with damped coagulation waveforms — this is of benefit in providing both a precise incision while simultaneously helping to control bleeding along the wound edges.
While wound tension after traditional primary closure can be associated with early post-operative restrictions to neck flexion or even result in baseline neck extension, these issues are circumvented with secondary intention healing (SIH).20,23 Concerns regarding wound dehiscence, which may complicate sutured closures, are also avoided with SIH. Post-operative pain, however, has been reported in some studies to be greater in wounds that were left open to heal versus those closed primarily with sutures.20,24 In patients managed with SIH, the possible need for oral analgesics should be anticipated in the first few days following surgery.
Scar widening has also been reported as a late complication after primary closure following AKN excision.24 This is not unexpected as these wounds are often under considerable tension on closure. Undoubtedly this level of tension is only aggravated by the strain associated with the remarkable mobility inherent to this region. Somewhat surprisingly, wounds left open for SIH on the posterior neck undergo significant post-operative contraction and once healed their appearance often rivals that of wounds closed primarily with sutures. Remarkably, recurrence rates following AKN excision have also been reported to be higher with primary closure than in wounds that are allowed to heal by secondary intention.25
Patient Outcome
Our patient denied any need for analgesics after his excision. This is contrary to a previously reported series that noted 4 of 4 AKN patients treated with electrosurgery and SIH required narcotic analgesics for pain control.24 We speculate that the hemostatic agent utilized for our patient to seal the wound and prevent hemorrhage may also have been associated with reduced early post-operative discomfort.
Our patient noted his wounds were fully healed 8 weeks following the procedure. Digital photos were captured at 12 weeks (Figure 3). The 2 large excision sites allowed to heal by secondary intention had contracted considerably in size and at 12 weeks were rated as “very acceptable” by the patient. Our close inspection did reveal a small amount of mildly hypertrophic scar on the right, but failed to show any further evidence of active AKN related inflammation or recurrent keloid-like scar. The patient remained recurrence free at 4 months follow-up.
Figure 3. Post-operative (12 weeks): Secondary healing with wound contraction.
In summary, though AKN can be vexing for patients — effective treatments are available. Electrosurgical excision in our patient appeared to provide a very satisfactory outcome and this has been confirmed in similar reports describing AKN excision followed by second intention healing.20,25 The use of a potassium ferrate containing polymer as a hemostatic agent in this case appeared to be well-tolerated and may be advantageous post-operatively in both limiting oozing and preventing subsequent bleeding. In our patient, post-operative discomfort also appeared to be diminished. Further investigation is warranted to confirm the post-operative utility of this hemostatic agent and its safety in deeper wounds left to heal secondarily.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Lortie is a procedural dermatology Mohs surgery fellow at Affiliated Dermatologists in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist and the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. George AO, Akanji, AO, Nduka EU, Olasode JB, Odusan O. Clinical, biochemical and morphologic features of acne keloidalis in a black population. Int J Dermatol. 1993;32(10):714-716.
2. Salami T, Omeife H, Samuel S. Prevalence of acne keloidalis nuchae in Nigerians. Int J Dermatol. 2007;46(5):482-484.
3. Azurdia RM, Graham RM, Weismann K, Guerin DM. Acne keloidalis in caucasian patients on cyclosporin following organ transplantation. Br J Dermatol. 2000;143(2):465-467.
4. Bajaj V, Langtry JA. Surgical excision of acne keloidalis nuchae with secondary intention healing. Clin Exp Dermatol. 2007;33(1):53-55.
5. Adegbidi H, Atadokpede F, do Ango-Padonou F, Yedomon H. Keloid acne of the neck: epidemiological studies over 10 years. Int J Dermatol. 2005;44(suppl 1):49-50.
6. Ogunbiyi A, George A. Acne keloidalis in females: case report and review of literature. J Natl Med Assoc. 2005;97(5):736-738.
7. Dinehart SM, Tanner L, Mallory SB, Herzberg AJ. Acne keloidalis in women. Cutis 1989;44(3):250-252.
8. Knable AL Jr, Hanke CW, Gonin R. Prevalence of acne football players. J Am Acad Dermatol. 1997;37(4):570-574.
9. Harris H. Acne keloidalis aggravated by football helmets. Cutis. 1992;50(2):154.
10. Grunwald MH, Ben-Dor D, Livni E, Halevy S. Acne keloidalis-like lesions on the scalp associated with antiepileptic drugs. Int J Dermatol. 1990;29(8):559-561.
11. Callender VD, Young CM, Haverstiock CL, Carroll CL, Feldman SR. An open label study of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of mild to moderate acne keloidalis. Cutis. 2005;75(6):317-321.
12. Shah GK. Efficacy of diode laser for treating acne keloidalis nuchae. Indian J Dermatol Venereol Leprol. 2005;71(1):31-34.
13. Esmat SM, Abdel Hay RM, Abu Zeid OM, Hosni HN. The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study. Eur J Dermatol. 2012;22(5):645-650.
14. Kantor GR, Ratz JL, Wheeland RG. Treatment of acne keloidalis nuchae with carbon dioxide laser. J Am Acad Dermatol. 1986;14(2 Pt 1):263-267.
15. Layton AM, Yip J, Cunliffe WJ. A comparison of intralesional triamcinolone and cryosurgery in the treatment of acne keloids. Br J Dermatol. 1994;130(4):498-501.
16. Bard C, Wolff M. Acne keloidalis. Plast Reconstr Surg. 1972;50(1):25-30.
17. Sidle DM, Kim H. Keloids: prevention and management. Facial Plast Surg Clin North Am. 2011;19(3):505-515.
18. Pestalardo CM, Cordero A Jr, Ansorena JM, Bestue M, Martinho A. Acne keloidalis nuchae. Tissue expansion treatment. Dermatol Surg. 1995;21(8):723-724.
19. Malherbe F. Sycosis nuchae and its surgical treatment. Plast Reconstr Surg. 1971;47(3):269-271.
20. Glenn MJ, Bennett RG, Kelly AP. Acne keloidalis nuchae: treatrnent with excision and second-intention healing. J Am Acad Dermatol. 1995;33 (2 Pt 1):243-246.
21. Biolife, LLC. Urgent QR product information. https://www.biolife.com. Accessed March 20, 2014.
22. Ho J, Hruza G. Hydrophilic polymers with potassium salt and microporous polysaccharides for use as hemostatic agents. Dermatol Surg. 2007;33(12):1430-1433.
23. Dinehart SM, Herzberg AJ, Kerns BL, Pollack SV. Acne keloidalis: a review. J Dermatol Surg Oncol. 1989;15(6):642-647.
24. Gloster HM Jr. The surgical management of extensive cases of acne keloidalis nuchae. Arch Dermatol. 2000;136(11):1376-1379.
25. Califano J, Miller S, Frodel J. Treatment of occipital acne keloidalis by excision followed by secondary intention healing. Arch Facial Plast Surg. 1999;1(4):308-311.
Acne keloidalis nuchae (AKN) is a frustrating dermatologic condition that is often as vexing for patients as it is challenging to manage for their consulting dermatologists. AKN presents with pustules and papules that may coalesce into larger keloid-like nodules located on the posterior concavity of the neck near the collar line.
A factor common to most AKN patients is the presence of coarse curly hair in this area.1 Higher testosterone levels have also been speculated to play a role.1 Black males are most often affected, although AKN has been noted less commonly in Asian, Hispanic and Caucasian patients.1-4 The condition occurs following adolescence with the vast majority of those affected being under age 40.5 Only rarely have women been reported to suffer from AKN.6,7
Other factors that may contribute include close shaving or clipping of hair and mechanical friction from collars or helmets.8,9 It has been described uncommonly in association with the use of medications, such as cyclosporine, and certain anti-epileptic drugs.3,10
In this article, we offer a brief overview of treatment options and report on a 39-year-old African American male with AKN treated with electrosurgical excision. This patient’s excision was followed by the topical application of a hemostatic agent and secondary intention healing.
Therapeutic Alternatives
Conservative treatments for AKN have included refraining from shaving or close trimming of hair in the affected area. Avoidance of mechanical occlusion from helmets or repetitive rubbing from shirt collars also appears to be of benefit. Topical antibacterial products containing benzoyl peroxide, erythromycin or clindamycin may also be therapeutic. However, if the skin is noted to be frankly infected, oral antibiotics should be considered in the short-term. If cultures are conducted, empiric antibiotics can be tailored to bacterial sensitivity results when they become available. Once mild disease has stabilized, it is often controlled with topical corticosteroids and possibly retinoids as well.11
Laser hair removal (LHR) can be specifically therapeutic and may be preventive early in the course of AKN. Often the major limitation is the effective use of LHR in darker skin types. Success has been reported, however, particularly with the longer wavelength 810 nm diode and 1064 nm NdYAG laser platforms.12,13 Carbon dioxide laser ablation has also been reported, but may be restricted by its limited ability to control brisk bleeding as well as prolonged post-operative healing times and relatively high recurrence rates.14
Intralesional triamcinolone acetonide injections are often first-line therapy once keloid-like papules and nodules appear.15 Cryotherapy can also be effective, but its use may be limited by concerns regarding post-treatment hypopigmentation, which can be particularly evident in darker Fitzpatrick skin types.15
Electrodesiccation under local anesthetic can debulk smaller lesions and may be less likely to result in hypopigmentation.16 As with the treatment of traditional keloid scars, local radiotherapy has also been employed for AKN.16 Patients treated with radiation may benefit from the permanent epilation sometimes associated with this therapy. Unfortunately, radiotherapy can also be accompanied by unwelcome post-radiation skin changes and the long-term carcinogenic risks associated with all ionizing radiation.16,17 As a result, its use in the treatment of AKN has fallen out of favor in recent years.
Surgical excision of AKN is generally reserved for refractory cases associated with a significant burden of keloid-like scar. Though smaller lesions may be removed with more basic techniques such as punch biopsy, larger lesions often require ellipse excision. Moderate post-operative defects may be closed primarily, but if more extensive skin deficits exist alternate approaches such as the use of tissue expanders have been employed.18 Skin grafting has also been utilized, but cosmetic outcomes are generally considered to be less favorable with this option.19 Finally, secondary intention healing is a practical alternative commonly employed for larger wounds though patients must be willing to commit to a prolonged course of wound care (as long as 6-12 weeks).
Case Report: Excision via Electrosurgery
Our patient presented with several fairly large scar-like nodules on the posterior aspect of his neck (Figure 1). He described that the lesions had enlarged progressively over the last few years despite numerous treatments with intralesional triamcinolone. The patient had become increasingly dissatisfied with these more conservative treatments and was interested in pursuing a surgical solution.
Figure 1. Pre-operative: Acne keloidalis nuchae with keloid-like scars.
Elective surgical excision was conducted following local infiltration of lidocaine with epinephrine. The keloid-like nodules were outlined with surgical marker incorporating a 3-mm to 4-mm margin. Though it is generally recommended that a single horizontal ellipse be conducted to include the posterior hairline, given the geometry and superior location of the lesions in this patient, we determined that a customized approach was more appropriate in this case.20
Consequently, we elected to proceed with 2 separate horizontal ellipses placed narrowly above the hairline. The lesions were excised with electrosection utilizing an Ellman Surgitron (Ellman International Inc; Hicksville, NY) in biterminal “cut/coag” mode (rectified, non-filtered) with a fine needle electrode. Electrosection in mixed “cut/coag” mode allowed for a clean incision with minimal tissue resistance. This mode simultaneously helped to provide management of concomitant bleeding on the highly vascular posterior scalp. To ensure that the excision was entirely sub-follicular, the tissue was incised down to the level of deep subcutaneous fat. Any bleeding points that remained were readily managed with additional focal electrocoagulation. The 2 open wounds that resulted were left to heal by secondary intention.
To help limit oozing and reduce the possibility of subsequent post-operative hemorrhage, we elected to apply WoundSeal (Biolife, LLC; Sarasota, FL) to the lesions following excision (Figure 2).
Figure 2. Intraoperative: Post-electrosection with hemostatic agent.
This hydrophilic powder is reported to dehydrate blood on contact.21 The powder contains an ion exchange resin including potassium ferrate, which instigates the agglutination of blood cells forming a hemostatic and occlusive seal. Though the literature accompanying WoundSeal recommends its use in wounds with a depth of 1 mm or less, the product has been reported to be beneficial in deeper wounds left to heal secondarily.21,22 The product’s reaction with blood is mildly exothermic. While some warming of the wound was evident following its application, in our patient no untoward effects were noted.
Traditional non-adhesive wound dressings were subsequently applied and our patient was discharged home. No prophylactic antibiotics were prescribed. Wound care instructions included twice daily, warm water soaks followed by the application of mupirocin ointment beneath a fresh dressing. These soaks eventually flushed away the residual hemostatic powder as well as any persistent serous crust.
Discussion
Cold-steel excision is challenging due to often brisk bleeding associated with scalp incision. Pure electrosection alone provides little if any advantage in this regard, but if settings are combined with damped coagulation waveforms — this is of benefit in providing both a precise incision while simultaneously helping to control bleeding along the wound edges.
While wound tension after traditional primary closure can be associated with early post-operative restrictions to neck flexion or even result in baseline neck extension, these issues are circumvented with secondary intention healing (SIH).20,23 Concerns regarding wound dehiscence, which may complicate sutured closures, are also avoided with SIH. Post-operative pain, however, has been reported in some studies to be greater in wounds that were left open to heal versus those closed primarily with sutures.20,24 In patients managed with SIH, the possible need for oral analgesics should be anticipated in the first few days following surgery.
Scar widening has also been reported as a late complication after primary closure following AKN excision.24 This is not unexpected as these wounds are often under considerable tension on closure. Undoubtedly this level of tension is only aggravated by the strain associated with the remarkable mobility inherent to this region. Somewhat surprisingly, wounds left open for SIH on the posterior neck undergo significant post-operative contraction and once healed their appearance often rivals that of wounds closed primarily with sutures. Remarkably, recurrence rates following AKN excision have also been reported to be higher with primary closure than in wounds that are allowed to heal by secondary intention.25
Patient Outcome
Our patient denied any need for analgesics after his excision. This is contrary to a previously reported series that noted 4 of 4 AKN patients treated with electrosurgery and SIH required narcotic analgesics for pain control.24 We speculate that the hemostatic agent utilized for our patient to seal the wound and prevent hemorrhage may also have been associated with reduced early post-operative discomfort.
Our patient noted his wounds were fully healed 8 weeks following the procedure. Digital photos were captured at 12 weeks (Figure 3). The 2 large excision sites allowed to heal by secondary intention had contracted considerably in size and at 12 weeks were rated as “very acceptable” by the patient. Our close inspection did reveal a small amount of mildly hypertrophic scar on the right, but failed to show any further evidence of active AKN related inflammation or recurrent keloid-like scar. The patient remained recurrence free at 4 months follow-up.
Figure 3. Post-operative (12 weeks): Secondary healing with wound contraction.
In summary, though AKN can be vexing for patients — effective treatments are available. Electrosurgical excision in our patient appeared to provide a very satisfactory outcome and this has been confirmed in similar reports describing AKN excision followed by second intention healing.20,25 The use of a potassium ferrate containing polymer as a hemostatic agent in this case appeared to be well-tolerated and may be advantageous post-operatively in both limiting oozing and preventing subsequent bleeding. In our patient, post-operative discomfort also appeared to be diminished. Further investigation is warranted to confirm the post-operative utility of this hemostatic agent and its safety in deeper wounds left to heal secondarily.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Lortie is a procedural dermatology Mohs surgery fellow at Affiliated Dermatologists in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist and the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. George AO, Akanji, AO, Nduka EU, Olasode JB, Odusan O. Clinical, biochemical and morphologic features of acne keloidalis in a black population. Int J Dermatol. 1993;32(10):714-716.
2. Salami T, Omeife H, Samuel S. Prevalence of acne keloidalis nuchae in Nigerians. Int J Dermatol. 2007;46(5):482-484.
3. Azurdia RM, Graham RM, Weismann K, Guerin DM. Acne keloidalis in caucasian patients on cyclosporin following organ transplantation. Br J Dermatol. 2000;143(2):465-467.
4. Bajaj V, Langtry JA. Surgical excision of acne keloidalis nuchae with secondary intention healing. Clin Exp Dermatol. 2007;33(1):53-55.
5. Adegbidi H, Atadokpede F, do Ango-Padonou F, Yedomon H. Keloid acne of the neck: epidemiological studies over 10 years. Int J Dermatol. 2005;44(suppl 1):49-50.
6. Ogunbiyi A, George A. Acne keloidalis in females: case report and review of literature. J Natl Med Assoc. 2005;97(5):736-738.
7. Dinehart SM, Tanner L, Mallory SB, Herzberg AJ. Acne keloidalis in women. Cutis 1989;44(3):250-252.
8. Knable AL Jr, Hanke CW, Gonin R. Prevalence of acne football players. J Am Acad Dermatol. 1997;37(4):570-574.
9. Harris H. Acne keloidalis aggravated by football helmets. Cutis. 1992;50(2):154.
10. Grunwald MH, Ben-Dor D, Livni E, Halevy S. Acne keloidalis-like lesions on the scalp associated with antiepileptic drugs. Int J Dermatol. 1990;29(8):559-561.
11. Callender VD, Young CM, Haverstiock CL, Carroll CL, Feldman SR. An open label study of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of mild to moderate acne keloidalis. Cutis. 2005;75(6):317-321.
12. Shah GK. Efficacy of diode laser for treating acne keloidalis nuchae. Indian J Dermatol Venereol Leprol. 2005;71(1):31-34.
13. Esmat SM, Abdel Hay RM, Abu Zeid OM, Hosni HN. The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study. Eur J Dermatol. 2012;22(5):645-650.
14. Kantor GR, Ratz JL, Wheeland RG. Treatment of acne keloidalis nuchae with carbon dioxide laser. J Am Acad Dermatol. 1986;14(2 Pt 1):263-267.
15. Layton AM, Yip J, Cunliffe WJ. A comparison of intralesional triamcinolone and cryosurgery in the treatment of acne keloids. Br J Dermatol. 1994;130(4):498-501.
16. Bard C, Wolff M. Acne keloidalis. Plast Reconstr Surg. 1972;50(1):25-30.
17. Sidle DM, Kim H. Keloids: prevention and management. Facial Plast Surg Clin North Am. 2011;19(3):505-515.
18. Pestalardo CM, Cordero A Jr, Ansorena JM, Bestue M, Martinho A. Acne keloidalis nuchae. Tissue expansion treatment. Dermatol Surg. 1995;21(8):723-724.
19. Malherbe F. Sycosis nuchae and its surgical treatment. Plast Reconstr Surg. 1971;47(3):269-271.
20. Glenn MJ, Bennett RG, Kelly AP. Acne keloidalis nuchae: treatrnent with excision and second-intention healing. J Am Acad Dermatol. 1995;33 (2 Pt 1):243-246.
21. Biolife, LLC. Urgent QR product information. https://www.biolife.com. Accessed March 20, 2014.
22. Ho J, Hruza G. Hydrophilic polymers with potassium salt and microporous polysaccharides for use as hemostatic agents. Dermatol Surg. 2007;33(12):1430-1433.
23. Dinehart SM, Herzberg AJ, Kerns BL, Pollack SV. Acne keloidalis: a review. J Dermatol Surg Oncol. 1989;15(6):642-647.
24. Gloster HM Jr. The surgical management of extensive cases of acne keloidalis nuchae. Arch Dermatol. 2000;136(11):1376-1379.
25. Califano J, Miller S, Frodel J. Treatment of occipital acne keloidalis by excision followed by secondary intention healing. Arch Facial Plast Surg. 1999;1(4):308-311.
