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Folliculitis keloidalis

Author: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Updated and reviewed by Dr Amanda Oakley and Clare Morrison, Copy Editor, April 2014.


Folliculitis keloidalis — codes and concepts
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What is folliculitis keloidalis?

Folliculitis keloidalis is an unusual form of chronic folliculitis (inflammation of hair follicle unit) and cicatricial alopecia (scarring hair loss) that affects the nape of the neck. 

Folliculitis keloidalis, or folliculitis keloidalis nuchae, is sometimes called acne cheloidalis nuchae or acne keloidalis. These names are incorrect because folliculitis keloidalis is not acne and the scars formed are not true keloids. The names are confusing, especially as acne can result in keloid scarring.

Folliculitis keloidalis

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Who gets folliculitis keloidalis?

folliculitis keloidalis is more common in dark-skinned people than in whites, and most often affects adult Afro-Caribbean males with black curly hair. It is 20 times more common in males than in females.

What does folliculitis keloidalis look like?

Initially, itchy round small bumps appear within or close to the hair-bearing area of the back of the neck (occipital scalp). These firm papules can be very itchy, and scratching can lead to secondary bacterial infection (Staphylococcus aureus. Sometimes there are pustules around the hair follicles (folliculitis).

As time goes on the bumps become small scars and then the small scars may greatly enlarge to become keloids. The scars are hairless and can form a band along the hairline. Tufted hairs may be present; these are multiple hair shafts emerging from a single follicular opening.

What is the cause of folliculitis keloidalis?

Some researchers have concluded that folliculitis keloidalis may begin with an injury during a close hair cut or use of a razor. It is thought to be a mechanical form of folliculitis, in which ingrown hair shafts irritate the wall of the hair follicle resulting in inflammation. This completely destroys the hair follicle and results in scarring.

Others argue that folliculitis keloidalis is a primary skin disease unrelated to either ingrown hairs or bacterial infection.

An association with obesity and metabolic syndrome has been observed in some patients.

How is folliculitis keloidalis diagnosed?

The diagnosis of folliculitis keloidalis is made clinically by finding follicular papules, pustules, and scars on the occipital scalp. The histology of folliculitis keloidalis nuchae is characteristic, should a biopsy be performed. 

What is the treatment for folliculitis keloidalis?

Unfortunately, folliculitis keloidalis often persists despite a variety of treatments. The following measures are sometimes helpful:

  • Making sure clothing and equipment, such as high collars and helmets, do not rub the back of the neck
  • Avoid a short or razor hair cut.
  • Wash the affected area using an antimicrobial cleanser to reduce secondary infection.
  • 2 to 4–week courses of topical steroids are useful if the papules are less than 3 mm in size
  • Steroids injected into the lesions (intralesional injections) are more suitable for large papules and plaques.
  • Oral tetracycline as an anti-inflammatory or other antibiotics for secondary infection
  • Laser-assisted hair removal has been shown to improve folliculitis keloidalis. Best results occur if treatment is started early before significant scarring has developed.
  • A three-month course of clindamycin and rifampicin antibiotics if infection persists
  • Surgery to removing large thickened plaques or nodules
  • Laser vaporisation or excision and electrosurgery are alternatives to surgery
  • Oral isotretinoin
  • Radiotherapy

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References

  • 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 Sep-Oct;22(5):645-50. doi: 10.1684/ejd.2012.1830. PubMed PMID: 23018044.
  • Alexis A, Heath CR, Halder RM. Folliculitis Keloidalis Nuchae and Pseudofolliculitis Barbae: Are Prevention and Effective Treatment Within Reach? Dermatol Clin. 2014 Apr;32(2):183-191. doi: 10.1016/j.det.2013.12.001. Review. PubMed PMID: 24680005.

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