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