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AKN is a chronic scarring folliculitis of the occipital scalp and nape of the neck. It produces keloid-like papules and plaques, but is neither true acne nor a true keloid. It results in permanent scarring alopecia if left untreated
What will the patient tell you? (History)
What will the patient tell you? (History)
The typical patient is usually a man (20:1 ratio) with darker skin tones (African, Afro-Caribbean, Hispanic, Middle Eastern, South Asian descent), with onset after puberty (late teens to 30s).
Symptoms:
Patients report a gradual onset of small, firm, itchy bumps at the back of the neck or occipital scalp. Over time, these papules and pustules coalesce into thick, raised plaques, often accompanied by permanent hair loss (scarring alopecia). Discomfort and tenderness are common.
Course:
The condition is chronic, relapsing, and often progressive without intervention, leading to significant psychosocial impact.
Risk Factors:
Tightly curled/coiled hair which predisposes to ingrown hairs.
Mechanical irritation from very close shaves (razors/fades), or friction from collars, helmets, or caps.
Cultural grooming practices (sharp line-ups) are particularly relevant in darker skin tones as they increase the risk of trauma.
Use of topical oils/greases that may occlude the follicles.
Image Sourced From Skin Sight
Image Sourced From Derm Net
What will it look like? (Examination)
Key findings are concentrated at the posterior hairline / occipital scalp / nape of the neck.
Early Stage:
Presents as firm, pruritic follicular papules (skin-coloured to red-brown) which may be accompanied by small pustules or crusting.Progressive Stage:
Papules coalesce into keloid-like hypertrophic plaques. Hairs may appear tufted ("doll's hair") where multiple hairs emerge from a single scarred follicle. The affected area develops smooth, hairless, raised bands or plaques (scarring alopecia).Crucial Note for Darker Skin Tones:
The lesions and plaques often appear dark brown to black, which can be mistaken for true keloids. Post-inflammatory hyperpigmentation (PIH) is common and can be a significant cosmetic concern. There is an increased risk of hypertrophic and keloid scarring from the disease process itself and from aggressive treatment.
How can you help? (Treatment)
The goal is to halt inflammation, minimize scarring, and prevent new lesions, while respecting the high risk of dyspigmentation and scarring in darker skin tones.
General Measures (Essential):
Stop close shaving: Avoid razors and short fades; use clippers to leave 1-2 mm of hair.
Reduce friction/trauma: Avoid tight collars, helmets, and chin straps.
Hygiene: Use antimicrobial cleansers or shampoos (e.g., chlorhexidine, benzoyl peroxide wash).
Avoid heavy hair greases/oils that occlude follicles.
Medical Therapy:
Mild to Moderate Disease: Use high-potency topical corticosteroids (e.g., clobetasol solution) combined with a topical antimicrobial (e.g., clindamycin) if pustules are present.
Moderate to Severe Disease: Oral tetracyclines (e.g., doxycycline/minocycline for 6–8+ weeks) are used for their anti-inflammatory effects.
Intralesional Corticosteroids (e.g., triamcinolone): Injections directly into thick papules/plaques can flatten and soften lesions. In darker skin tones, use low-to-moderate doses and counsel about the risk of hypopigmentation.
Refractory/Extensive Disease:
Laser Hair Removal (e.g., long-pulse Nd:YAG): Targets the hair follicle to reduce the inflammatory drive. Preferred in experienced hands for darker skin tones.
Surgical Excision: Can remove bulky fibrotic plaques, but must be combined with other therapies (like intralesional steroids) as recurrence is possible, and meticulous technique is needed to minimize scarring.
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