Professional Documents
Culture Documents
, 2007
Printed in the United States All rights reserved
DERMATOLOGIC THERAPY
ISSN 1396-0296
Acne keloidalis nuchae, also known as folliculitis its antimicrobial and antiinflammatory effect),
nuchae, is a chronic scarring folliculitis charac- and a series of intralesional steroids (40 mg/cc of
terized by fibrotic papules and nodules of the existing keloids). Education is the key to preven-
nape of the neck and the occiput. It particularly tion. I discourage high-collared shirts, short hair-
affects young men of African descent and rarely cuts, and close shaving or cutting the hair along
occurs in women; in either case its occurrence the posterior hairline. In the long-term, patients
has a significant impact on the patients quality benefit from laser hair removal using diode or
of life. Weve asked our experts to share their expe- Nd:YAG, which helps avoid disease progression.
rience in helping patients with this cosmetically Early treatment decreases the morbidity that can
disfiguring disorder. be associated with late-stage disease.
Dr. Badreshia: Initially, I treat acne keloidalis Dr. Swinehart: Acne keloidalis nuchae can be
nuchae with topical steroids, oral doxycycline (for treated with trimethoprim or isotretinoin in an
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Acne keloidalis nuchae
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Acne keloidalis nuchae
lesion should be excised in one, two, or even three Dr. Badreshia: I rule out any underlying or associ-
stages. Complications may occur if the surgeon ated conditions through a history and physical
excises a large keloid in one stage and subse- examination including the follicular occlusion
quently attempts to close the resulting defect under triad (acne conglobata, hidradenitis suppurativa,
excessive tension. Spread scars and restricted and pilonidal sinus). If there is drainage, cultures
movement may be avoided if large keloids are are ordered. To calm down active inflammation
excised in two stages, thus allowing the surgeon to and drainage, I prescribe oral antibiotics and pre-
close the resulting defect without undue tension. dnisone. Isotretinoin, which can change the pattern
of follicle keratinization and suppresses sebaceous
Dr. Breadon: Patients with advanced keloidal gland activity, is prescribed at a dose of 1 mg/kg/
lesions require some form of surgical inter- day for at least 4 months after the disease is clini-
vention. I havent detected a marked difference cally inactive. Concomitant therapies for resistant
in the response of patients who undergo surgical lesions include intralesional steroid, incision and
procedures with either scalpel excision (cold drainage, and local excision. Laser treatment with
steel), carbon dioxide laser excision with the laser diode and Nd:YAG can be an excellent treatment
beam in the focused mode, or carbon dioxide once active disease is controlled.
laser vaporization in the defocused mode. If there
is sufficient nuchal scalp laxity and the keloidal Dr. Vause: Culture. Start with a loading dose of oral
plaque is small lying in a horizontal orientation, antibiotics tapering as symptoms improve. Long-
excision with primary side-to-side closer is per- term maintenance therapy may be necessary.
formed. If there is a broad area of scalp involve- Prescribe a steroid shampoo, solution and/or
ment, I perform tangential shave excision of the perform intralesional injections. Instruct patients
lesion(s), with healing by secondary intention. The to avoid occlusive pomade hair preparations and
patient is treated with immediate postoperative excessive scalp manipulation.
intralesional triamcinolone, 10 mg/cc to the surgical
site(s), as well as monthly triamcinolone injections Dr. Brauner: I have fortunately seen it only very
thereafter, ranging from 5 to 20 mg/cc strength, rarely but would culture the area and treat with
typically for up to 6 months or longer in patients appropriate antibiotics followed by beginning
who have undergone either type of surgical excision. with isotretinoin.
Questions on dissecting cellulitis and folliculitis Dr. Breadon: Early intervention and education is
decalvans: essential. I start patients on high-dose oral zinc
gluconate or sulfate, 220 mg three times daily with
Question food, indefinitely. I often treat with minocycline,
100 mg twice daily. Daily scalp cleansing with
What is your approach to treating patients with Phisohex can be helpful. Intralesional injections
perifolliculitis capitis abscessens et suffodiens (dis- are administered at the time of the initial visit and
secting cellulitis of the scalp)? monthly. Active, fluctuant lesions as well as scarred/
fibrotic lesions are injected with triamcinolone, in
Response concentrations of 10-20-40 mg/cc, depending on
the severity of the fibrosis. Very fibrotic lesions are
Dr. Quarles: A 21-gauge needle and vacutainer excised and closed primarily.
connected to a red-top test tube is a simple means
of aspirating any seropurulent material within the Dr. Swinehart: Dissecting cellulitis and folliculitis
abscess nonsurgically. Cultures are taken but are decalvans generally respond to broad-spectrum
invariably negative as these abscesses are sterile. antibiotics or isotretinoin.
In the rare case of bacterial growth, it is probably a
result of previous rupture and becomes secondary Dr. Brody: I use sulfa and rifampin after obtain-
infection. Intralesional triamcinolone 40 mg/cc is ing cultures in both dissecting cellulites and
injected into the evacuated abscess and (1) pre- pseudofolliculitis.
dnisone 60 mg initially tapered by 5 mg in the
morning and (2) trimethoprim sulfide double- Question
strength 20 mg bid for 10 days is prescribed.
Maintenance therapy is tetracycline 500 mg twice How do you treat patients with folliculitis
daily. decalvans?
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Acne keloidalis nuchae
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Acne keloidalis nuchae
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