Diagnosis: Follicular keloidalis
The patient was diagnosed with follicular keloidalis, an inflammatory process with keloidlike papules and plaques on the occipital scalp and posterior neck. Occurring almost exclusively in African-American men, the disorder is also known as “acne keloidalis (or cheloidalis),”“folliculitis keloidis nuchae,” “dermatitis papillaris capillitii,” “sycosis nuchae,” and “keloidal folliculitis.”
The first sign is usually the onset of 2- to 4-mm dome-shaped papules on the posterior scalp and neck. Scratching and/or combing may result in open sores and pustules. The papules may remain discrete or may coalesce to form horizontal bands or irregular plaques. While the plaques are usually only a few centimeters in diameter, they can grow to as large as 10 cm. A large portion of the posterior scalp may be involved even when only papules are present. The fibrosis associated with these papules leads to either patchy alopecia or complete hair loss in the affected areas.
Patients have a tendency to scratch and pick at the lesions, even if there is no pruritus. As a result, a secondary infection with pustulation occasionally occurs. Although bacterial infections can be a component, no specific organism has been isolated. This condition is chronic, and new lesions may form at intervals for years.
Various activities are suspected of causing follicular keloidalis but remain unproved. These include irritation from collars, hygiene practices, close clipper haircuts, shaving, prolonged use of pomades, and acne mechanica, due, for example, to friction from football helmets.
In a large series of patients with follicular keloidalis, the only universal parameter was the habit of excoriating the nuchal skin area. This led to the belief that the disorder represents a variant of lichen simplex chronicus (a condition resulting from excessive scratching) in a skin region with a predilection for keloid formation in African Americans.1 This etiology is in accordance with the tendency of African Americans to develop scars from papules in eczematous states. The histology also supports a connection between follicular keloidalis and lichen simplex chronicus, as sclerotic changes in the collagen appear with secondary atrophy of the follicles and sebaceous glands. Thus the pathologic features are characteristic of the fibrosis seen in lichen simplex chronicus and not standard keloid formation. While Caucasian skin responds to long-term scratching and digging with lichenification and calluslike skin, African-American skin has a more exuberant dermal fibrotic response, with scarring.
Although our patient believed that his lesions were caused by a short clipper haircut, such is not the case. Follicular keloidalis was present in the days of the Afro. Moreover, the condition often worsens long after development of the scarred nuchal region.
Our patient was instructed not to scratch the affected areas with his fingers, hairbrushes, or hair picks. He was given a topical steroid solution to apply daily to reduce the pruritus and, hopefully, some of the recent fibrosis. A four-month course of minocycline 50 mg b.i.d. was given to eliminate any remaining bacterial component. Unfortunately, much of the past scarring will not dissipate with medical treatment. In four months, our patient will be reassessed for further treatment to reduce the scarring, such as steroid injections, surgical or carbon-dioxide laser resection, or tissue expansion.
Dr. Burkhart is a clinical professor of dermatology at the Medical College of Ohio in Sylvania.
1. Burkhart CG, Burkhart CN. Acne keloidalis is lichen simplex chronicus with fibrotic keloidal scarring. J Am Acad Dermatol. 1998;39(4 Pt 1):661.