Acne Keloidalis Nuchae: Symptoms, Types, Causes and Treatment

Acne Keloidalis Nuchae (AKN) is a chronic, often disfiguring skin condition that primarily affects the nape of the neck and occipital scalp, particularly in men of African descent. Despite its name, AKN is not a true keloid, but rather a form of scarring folliculitis that can significantly impact quality of life due to both its appearance and its symptoms. In this article, we’ll explore the key aspects of AKN: its symptoms, how it presents in different forms, what causes it, and the latest evidence-based approaches to treatment.

Symptoms of Acne Keloidalis Nuchae

Living with AKN can be distressing, both physically and emotionally. Symptoms range from small bumps to large, scar-like plaques that can be itchy, painful, and sometimes bleed, particularly during haircuts or shaving. Recognizing these signs early can help prevent progression and scarring.

Main Symptom	Description	Impact	Source(s)
Papules/Nodules	Small, firm, flesh-colored or red bumps	Itching, discomfort	1 2 3 4
Plaques	Merged bumps forming flat, thickened areas	Disfigurement, alopecia	3 4
Tumorous Masses	Large, raised, keloid-like lesions	Pain, bleeding, scarring	3 4 5
Pustules	Bumps with pus, often with infection	Pain, risk of abscess	2 4
Scarring Alopecia	Permanent hair loss in affected areas	Cosmetic concern	2 4 5

Table 1: Key Symptoms

Early Signs and Common Complaints

AKN often starts subtly, with small bumps (papules or nodules) on the nape of the neck or occipital scalp. These may be flesh-colored, red, or slightly tender. Itching (pruritus) is common and can be intense, sometimes leading to scratching and further irritation 1 2 4. As the disease progresses, these bumps can merge to form larger plaques, and in advanced cases, tumorous masses may appear, which can bleed on contact—especially during shaving or haircuts 2 4.

Complications and Secondary Symptoms

Over time, chronic inflammation can lead to permanent hair loss (scarring or cicatricial alopecia) in the affected region 2 4 5. Secondary bacterial infection may lead to the development of pustules, sinuses, or even abscess formation, adding to discomfort and potential for further scarring 2.

Impact on Daily Life

The physical symptoms of AKN often translate into significant emotional and social distress. Patients may feel self-conscious about their appearance or experience anxiety over the possibility of bleeding and infection during grooming 1 4. In some communities, the bumps are colloquially known as "bumps," and the social stigma can be severe 5.

Types of Acne Keloidalis Nuchae

AKN isn’t a one-size-fits-all condition. Its appearance and severity can vary widely among individuals. Recognizing the different types can guide both prognosis and treatment.

Type	Description	Location/Extent	Source(s)
Papular	Small, discrete or clustered bumps	Localized	3 4 13
Nodular	Larger, firm nodules	May coalesce	3 4
Plaque	Flat, thickened areas from merged bumps	Widespread, large areas	3 4 13
Tumorous Mass	Large, keloid-like, raised lesions	Extensive, severe cases	3 4 5

Table 2: Clinical Types of AKN

Clinical Classification

A recent classification system divides AKN based on lesion distribution, size, and type 3:

• Tier 1: Lesion Distribution and Size
  • Class I–IV: Defined by sagittal width and location, from small, limited areas (Class I) to widespread scalp involvement (Class IV).
• Tier 2: Lesion Type
  • Papules/Nodules: Early, localized disease.
  • Plaques: Formed by merging of papules/nodules, often with more advanced scarring.
  • Tumorous Masses: Large, raised, keloid-like lesions, more common in patients of African descent 3.
• Tier 3: Associated Scalp Disease
  • Presence of other scarring alopecias such as folliculitis decalvans or dissecting cellulitis 3 4.

Progression of Lesions

• Papular/nodular lesions are usually the earliest and most responsive to treatment.
• Plaques and tumorous masses represent advanced disease, are more resistant to therapy, and are associated with greater cosmetic and symptomatic burden 3 4 13.
• Secondary infection may introduce pustules or abscesses, complicating management 2 4.

Demographic Patterns

The vast majority of cases occur in post-pubertal men of African ancestry, with peak incidence in young adulthood. Cases in women and other ethnicities are rare but have been reported 1 3 4.

Causes of Acne Keloidalis Nuchae

The exact cause of AKN remains elusive, but research points to a complex interplay of genetic, hormonal, mechanical, and environmental factors.

Factor	Role in AKN Development	Risk Group/Affect	Source(s)
Genetics	Higher prevalence in African descent	African males	1 3 4 5 7
Androgens	May increase scalp susceptibility	Post-pubertal men	4 5
Trauma	Friction from clothing/shaving, mechanical injury	All	2 4 5 7
Ingrown Hairs	Triggers follicular inflammation	Curly/coarse hair	4 5 7
Obesity	May increase skin folds/friction	Overweight	8
Infection	Secondary infection worsens inflammation	All	2 4 5

Table 3: Contributing Causes

Genetic and Ethnic Predisposition

AKN most commonly affects males of African descent, with prevalence rates in this group ranging from 0.45% to 16% 1 3 4 5. The reasons for this are not fully understood, but genetic factors, hair type (curly, coarse), and skin characteristics are implicated 1 5.

Role of Androgens and Hormonal Factors

The condition almost exclusively develops after puberty and is rare after age 55, suggesting a role for androgens (male hormones) in making the scalp more susceptible to follicular inflammation 4 5.

Mechanical Factors: Friction, Shaving, and Trauma

Mechanical irritation—such as repeated shaving, tight collars, sports equipment, or friction from clothing—can trigger or exacerbate AKN by causing microtrauma to the hair follicles 2 4 7. Ingrown hairs, particularly in those with curly hair, can lead to chronic folliculitis and eventual scarring 4 5 7.

Obesity and Metabolic Factors

Emerging evidence suggests that overweight and obesity may play a role, possibly by increasing skin folds and friction in the nape area, thereby promoting inflammation and follicular occlusion 8.

Infection and Inflammation

While AKN is not primarily infectious, secondary bacterial infection can worsen the condition, leading to pustules, abscesses, and more extensive scarring 2 4 5. Chronic inflammation is a key driver of the fibrotic (scarring) process 2 4.

Environmental and Cultural Practices

Unsafe shaving habits, such as sharing razors, can contribute not only to trauma but also pose risks for blood-borne infections in affected individuals 4. Attempts to self-treat with corrosive substances may worsen scarring 4.

Treatment of Acne Keloidalis Nuchae

Managing AKN can be challenging, and no single therapy guarantees a cure. Treatment aims to reduce inflammation, prevent scarring, and improve cosmetic appearance, with early intervention offering the best outcomes.

Treatment	Approach/Modality	Suitability/Notes	Source(s)
Antibiotics	Oral/topical for infection/inflammation	Early/active lesions	2 4 11
Corticosteroids	Topical/intralesional for inflammation	Plaques, nodules	2 4 11 13
Retinoids	Oral/topical to reduce follicular plugging	Adjunctive	2 11
Laser Therapy	CO2, Nd:YAG, diode, alexandrite lasers	Papular/plaque lesions	10 11 12 13
Surgical Excision	Removal of lesions with healing by 2nd intent	Severe/tumorous cases	9 11
Cryotherapy	Targeted freezing of small lesions	Select cases	2 11
Electrosurgery	Destruction of lesions by electric current	Select cases	2 11
Lifestyle	Avoid trauma, safe shaving, weight control	Prevention, adjunct	4 8

Table 4: Evidence-Based Treatments

Medical Management

• Antibiotics: Topical or oral antibiotics are often first-line for active inflammation or secondary infection. They help reduce bacterial load and inflammation but may require prolonged use 2 4 11.
• Corticosteroids: Topical steroids or intralesional steroid injections (e.g., triamcinolone) are used to suppress inflammation and reduce lesion size, particularly in plaques and nodules 2 4 11 13.
• Retinoids: These can be used to decrease follicular plugging, especially in early or mild cases 2 11.

Laser and Light Therapy

Laser hair reduction therapies, such as the 755-nm alexandrite laser, 810-nm diode laser, and 1,064-nm Nd:YAG laser, have shown significant effectiveness, especially for papular and early plaque lesions 11 12 13. These treatments can lead to substantial improvement with minimal side effects, such as temporary redness or hair loss, and are well-tolerated by patients 12 13.

• Best results are seen in early lesions (papules/pustules).
• Larger plaques and tumorous masses are less responsive to laser therapy 12 13.

Surgical Approaches

For extensive, resistant, or tumorous AKN, surgical excision of the affected area may be necessary. Healing by second-intention (allowing the wound to heal naturally) after a horizontal elliptical excision often provides the best cosmetic results 9. However, surgery is invasive, requires significant recovery, and may result in scarring 9 11.

Other Procedural Treatments

• Cryotherapy and electrosurgery may be used for small or recalcitrant lesions but are less commonly employed 2 11.

Prevention and Lifestyle Modifications

• Avoidance of trauma (gentle shaving, avoiding tight collars/hats)
• Early treatment at the onset of symptoms
• Adopting safe shaving and grooming practices to prevent infection spread
• Weight management in overweight/obese patients to reduce risk or severity 4 8

Limitations and Recurrence

Despite a range of therapies, recurrence is common, especially if underlying risk factors are not addressed. Early disease responds best to treatment; advanced cases often require a combination of medical and surgical interventions 11 12 13.

Conclusion

Acne Keloidalis Nuchae is a complex, chronic skin disorder that primarily affects young men of African descent. Its symptoms range from small itchy bumps to large, disfiguring plaques and masses. Understanding its types, causes, and the latest evidence-based treatments can lead to better outcomes and improved quality of life.

Key Points:

• AKN is a chronic scarring condition most often affecting the nape/occipital scalp in post-pubertal men of African descent 1 3 4 5.
• Symptoms include papules, plaques, tumorous masses, infection, and scarring alopecia—all of which can impact self-esteem and daily functioning 1 2 3 4 5.
• Causes are multifactorial: genetics, hormones, mechanical trauma, ingrown hairs, obesity, and secondary infection all play roles 2 3 4 5 7 8.
• Treatment is multi-modal, including antibiotics, corticosteroids, laser therapies, surgery, and lifestyle modification 2 4 9 10 11 12 13.
• Early intervention and preventive measures—such as safe shaving and weight management—are crucial to minimizing long-term scarring and improving outcomes 4 8.

If you or someone you know is experiencing symptoms of AKN, it is important to seek early dermatological consultation to discuss personalized treatment options and prevent progression to permanent scarring.