Derm Dx: Painful purulent nodules on the scalp - Clinical Advisor

Derm Dx: Painful purulent nodules on the scalp

Slideshow

  • Acne keloidalis nuchae 1_0813 Derm Dx

  • Acne keloidalis nuchae 12_0813 Derm Dx

A 45-year-old Hispanic patient presents with a six-year history of painful and progressively enlarging nodules on his occipital scalp and posterior neck. He also reports that he has lost hair in the affected region. These nodules drain purulent fluid when compressed.

Acne keloidalis nuchae, also referred to as acne keloidalis and folliculitis keloidalis, is a type of scarring alopecia, which has a significant tendency to affect black men. This condition has been reported to be 10 times more common in black...

Submit your diagnosis to see full explanation.

Acne keloidalis nuchae, also referred to as acne keloidalis and folliculitis keloidalis, is a type of scarring alopecia, which has a significant tendency to affect black men. This condition has been reported to be 10 times more common in black patients compared with white patients. In our practice, it is not uncommon to see acne keloidalis nuchae in Hispanic patients. 

The condition usually starts with itchy folliculocentric pustules at the nape of the neck and ultimately progresses to keloid-like plaques. Purulent sinus tracts, broken hairs and multiple hairs growing out of a single enlarged follicular ostia, also known as “dolls hairs”, may be evident. 

When biopsied, histological features include a perifollicular, lymphaplasmocytic infiltrate involving the lower infundibulum and isthmus, sebaceous gland loss, lamellar fibroplasia, and even complete follicular obliteration.

The pathoetiology of acne keloidalis is unknown. The condition may be incited or exacerbated by chronic friction (from wearing football helmet for example), close shaving of curly hairs and frequent haircuts (more than once a month). 

The differential diagnosis of scarring alopecia may include: central centrifugal cicatricial alopecia, lichen planopilaris, discoid lupus erythematosus and dissecting cellulitis of the scalp.

Central centrifugal cicatricial alopecia, also known as hot comb alopecia, typically is indolent, involves the vertex of the scalp and most commonly affects African American women.

Lichen planopilaris manifests clinically with perifollicular scale that evolves into a smooth permanent hair loss.  

Discoid lupus erythematosus commonly involves the scalp and presents as a patch of alopecic erythematous skin with an inflammatory border.

Dissecting cellulitis of the scalp involves purulent sinus tracts within the subcutaneous fat and lower dermis. Patients present with painless boggy nodules involving the mid to posterior vertex and upper occiput of the scalp.

Achieving the best treatment outcome for acne keloidalis nuchae depends on treating the condition early in the disease process (i.e. when papules initially present). Treatment with long-term topical clobetosol and oral doxycycline may not cure the condition, but it has been shown to slow the progression. Surgical excision is necessary for scar-like plaques and sinuses.

References

  1. Bolognia J, Jorizzo J, Schaffer J. Dermatology. China: Elsevier, 2012.
  2. James WD, Berger TJ, Elston DM et al. “Chapter 13: Acne.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
Next hm-slideshow in Clinical Quiz