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Acne keloidalis nuchae (AKN) is a rare chronic inflammatory condition most commonly treated medically but in severe, treatment-refractory cases, surgery can be a better solution. In this case report, we present a patient with severe refractory AKN, treated with excision and direct split-thickness skin grafting in combination with negative pressure wound therapy. The patient achieved a satisfactory cosmetic and functional result within a relatively short healing period of six weeks., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Acne keloidalis is a primary scarring alopecia characterized by longstanding inflammation in the scalp causing keloid-like scar formation and hair loss. Histologically, acne keloidalis is characterized by mixed leukocytic infiltrates in the acute stage followed by a granulomatous reaction and extensive fibrosis in the later stages. To further explore its pathogenesis, bulk RNA sequencing, single-cell RNA sequencing, and spatial transcriptomics were applied to occipital scalp biopsy specimens of lesional and adjacent no-lesional skin in patients with clinically active disease. Unbiased clustering revealed 19 distinct cell populations, including 2 notable populations: POSTN + fibroblasts with enriched extracellular matrix signatures and SPP1 + myeloid cells with an M2 macrophage phenotype. Cell communication analyses indicated that fibroblasts and myeloid cells communicated by SPP1 signaling networks in lesional skin. A reverse transcriptomics in silico approach identified corticosteroids as possessing the capability to reverse the gene expression signatures of SPP1 + myeloid cells and POSTN + fibroblasts. Intralesional corticosteroid injection greatly reduced SPP1 and POSTN gene expression as well as acne keloidalis disease activity. Spatial transcriptomics and immunofluorescence staining verified microanatomic specificity of SPP1 + myeloid cells and POSTN + fibroblasts with disease activity. In summary, the communication between POSTN + fibroblasts and SPP1 + myeloid cells by SPP1 axis may contribute to the pathogenesis of acne keloidalis., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

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Competing Interests: Competing interests: None declared.

Background: Acne scarring can be divided into 2 types: atrophic and hypertrophic scars. Papular acne scars are commonly encountered, skin-colored papules on the chin and back., Objective: This study aimed to estimate the prevalence of each acne scar type and to investigate the clinical manifestations of papular acne scars., Methods: This retrospective study included 416 patients with acne scars. Dermatologists classified the scars into 3 types (atrophic, papular, and keloid type) based on clinical photographs and analyzed the clinical and histologic features of papular acne scars., Results: Among 416 patients with acne scars, 410 patients (98.56%) had atrophic scars, 53 patients (12.74%) had keloid scars, and 46 patients (11.06%) had papular acne scars. Twenty patients (4.81%) had both papular and keloid acne scars. Histologic analysis showed fibrotic tissue in both keloid and papular acne scars. Fibrosis of the papular scar was limited to the upper dermis., Conclusion: Papular acne scars were significantly more prevalent in patients with keloid scars than in those without keloid scars. These results provide a basis for understanding papular acne scars, which have been under-recognized. The association between papular and keloid acne scars can suggest the decision for scar treatment., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this case-control study was to identify risk factors associated with acne keloidalis nuchae (AKN), seen in a dermatology clinic in Lomé (Togo)., Patients and Methods: This was a case-control study conducted from January to December 2018. Patients were recruited at outpatients dermatological clinics and controls were recruited at outpatients dermatological clinics and then in other hospital departments., Results: We recruited 303 consenting subjects, comprising 101 patients with AKN and 202 controls case-matched by age (±5 years). The mean patient age was 34.9±10.7 years vs. 35.6±11.2 years for controls. The most frequently observed AKN lesions were papules (73/101; 72.2%), fibrous scars (42/101; 41.5%) and folliculitis/pustules (41/101; 40.6%). In multivariate analysis, the following factors were associated with AKN: excess weight (adjusted odds ratio=4.8; 95% CI=[2.3-11.7]) or obesity (OR=9.2; 95% CI=[2.1-34.2]), bleeding during hairdressing either occasionally (aOR=13.9; 95% CI=[5.1-40.0]) or systematically (aOR=22.1; 95% CI=[6.2-40.7]), hairdressing procedures less than once per week (aOR=10.1; 95% CI=[3.2-50.8]), and extremely close cropping of hair (aOR=4.9; 95% CI=[2.8-15.5])., Conclusion: AKN is common in young adults. Excess weight or obesity, bleeding during hairdressing, and frequency and style of hairdressing are all associated factors. The results of this study stress the importance of limiting injury during hairdressing, and of refraining from shaving or cropping hair without a trimmer. Since management of AKN is extremely difficult, identification of associated risk factors allows suitable preventive approaches to be adopted., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Acne keloidalis (AK) is one of the primary cicatricial alopecias and predominantly affects men of African descent. Reports in Asians are scant. This study aimed to retrospectively review the clinical and histopathological features of AK patients in southern Taiwan and identify the pathognomonic features of AK. There were 15 patients with histopathologically confirmed AK in National Cheng Kung University Hospital between 1988 and 2018. The median onset age was 24 years (range, 14-71). The male : female ratio was 14:1. In the acute stage of AK, the lymphocytic and neutrophilic peri-infundibular inflammatory infiltrates with microabscess formation and edema corresponded to the clinical finding of isolated papules or pustules. Subsequently, the inflammatory infiltrates involved the mid-dermis and the isthmus of hair follicles. The "spade sign", a thin and dilated space resembling the shape of a balloon or spade symbol of playing cards at the level of lower isthmus, was identified in eight biopsies from five patients and may be a pathognomonic sign in the subacute stage of AK. At the chronic stage, the segments of hair shafts remained in the upper to mid-dermis and induced chronic inflammation and extensive fibrosis, resulting in the clinical keloid-like appearance. The restriction of inflammation and fibrosis in the upper to mid-dermis was another unique and pathognomonic feature of AK., (© 2019 Japanese Dermatological Association.)

Background: Acne keloidalis nuchae (AKN) is a chronic scarring folliculitis with limited interventions of both high efficacy and low morbidity., Objective: To assess the efficacy of the long-pulsed 1064-nm neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser and topical steroids as a treatment for AKN compared to topical steroids alone., Methods: We conducted a single-blinded, randomised, within-patient right-left controlled trial (n = 13). Eight monthly laser treatments were performed on the treated half of the scalp, and triamcinolone 0.1% cream was applied to both sides twice daily. Treatment response was measured using a global assessment score (0 to 10)., Results: The laser-treated side showed greater improvement in global assessment score. The mean change was -3.2 (-49.2%) on the treated side and -2.2 (-32.8%) on the control side ( P = .144). Papules responded well to laser treatment, while larger plaques and nodules showed limited improvement. In the 10 patients with papules only, the difference in improvement between the treated and control sides was statistically significant (mean change was -3.5 [-59.3%] for the treated side and -1.8 [-29.5%] for the control side, P = .031)., Limitations: This study was limited by a small sample size and a high dropout rate, as well as the lack of a standardised scoring system for AKN., Conclusion: The long-pulsed Nd:YAG laser in conjunction with topical steroids shows promising results in the treatment of AKN, particularly the papular component, and is well tolerated by patients.

Acne keloidalis nuchae, a type of folliculitis involving the back of the neck, is common in black men, although rare cases have been reported in patients of other ethnicities. We analyzed the clinicopathological features of acne keloidalis nuchae in 17 Asians. Patients' age at the time of presentation ranged from 20 to 69 years. Most patients experienced the disease over 2 years (range, 3 months-20 years); follow-up data were available for 11 (65%) patients (range, 2-95 months). Nine (53%) patients had comorbidities, but none had a history of other skin disease or a family history of acne keloidalis nuchae. Macroscopically, seven (41%) patients had multiple erythematous pustulopapular lesions, and 10 (59%) had a single large plaque. Histopathologically, deep scarring folliculitis containing naked hair shafts was identified. In all cases, inflammation was most severe in the upper two-thirds of the dermis, and the differences in pustulopapular and plaque lesions were more prominent in the peri-inflammation area. Of the seven patients with plaque lesions treated with steroids alone or steroids and cryotherapy, three experienced plaque reduction. Acne keloidalis nuchae occurring in Asian patients frequently present with typical clinicopathological features, and therefore in spite of very low incidence the diagnosis of this disease entity should be considered in idiopathic scarring folliculitis of the posterior neck.

Primary cicatricial alopecias can be frustrating for both patients and physicians. Proper diagnosis guides more successful management of these challenging conditions. Part II will cover the remaining lymphocytic primary cicatricial alopecias, which include pseudopelade of Brocq, central centrifugal cicatricial alopecia, alopecia mucinosa, and keratosis follicularis spinulosa decalvans. It will also discuss the neutrophilic and mixed primary cicatricial alopecias, namely folliculitis decalvans, dissecting cellulitis, folliculitis keloidalis, folliculitis (acne) necrotica, and erosive pustular dermatosis., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

The diagnosis of disorders of the hair and scalp can generally be made on clinical grounds, but clinical signs are not always diagnostic and in some cases more invasive techniques, such as a biopsy, may be necessary. This 2-part article is a detailed review of the histologic features of the main types of alopecia based on the traditional classification of these disorders into 2 major groups: scarring and nonscarring alopecias. Scarring alopecias are disorders in which the hair follicle is replaced by fibrous scar tissue, a process that leads to permanent hair loss. In nonscarring alopecias, the follicles are preserved and hair growth can resume when the cause of the problem is eliminated. In the second part of this review, we describe the histologic features of the main forms of scarring alopecia. Since a close clinical-pathological correlation is essential for making a correct histopathologic diagnosis of alopecia, we also include a brief description of the clinical features of the principal forms of this disorder., (Copyright © 2014 Elsevier España, S.L.U. and AEDV. All rights reserved.)

Follicular disorders are possibly a commonly seen, though rarely reported, group of disorders, which are localized around follicles and appendages and clinically present as small papules. Classically, clinicopathological follicular plugging is seen in the "true" follicular disorders, which are appropriately referred to as follicular keratosis. Another subtype is folliculitis (infectious or noninfectious) and the follicular mimickers that clinically resemble "true" follicular disorders without the follicular keratoses. Acne vulgaris has an amalgamation of all the above lesion types. Our review is aimed at describing all the follicular disorders and gives an algorithm for diagnosing the common follicular disorders., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Acne conglobata is hardly curable and easily leads to scar formation after treatment using traditional methods., Aim: To develop a novel way to treat acne conglobata., Methods: Seventy-five patients with facial acne conglobata were included in this clinical study and divided into either a treatment group (n = 35) to receive photodynamic therapy (PDT) with topical 5% 5-aminolevulinic acid and red light once every 10 days for a month or a control group (n = 40) to receive a Chinese herbal medicine mask plus red light once per week for the same duration. Patients in both groups were given oral viaminate capsules, doxycycline, zinc gluconate, and topical metronidazole. Efficacy was evaluated with respect to symptom score, cure rate, and response rate up to 2 weeks following the final treatment, and time points for assessment included baseline (D0 ), the visit before each treatment (D10 and D20 for the treatment group, and D7 , D14 , and D21 for the control group), and 2 weeks after treatment (D34 for the treatment group and D35 for the control group). Safety was assessed by recording adverse effects., Results: Treatment with PDT significantly improved acne lesions and reduced scar formation. The treatment group had a significantly lower symptom score, a higher cure rate, and response rate than the control group. No systemic side effects occurred., Conclusion: The treatment of acne conglobata with PDT is associated with a high cure rate, short treatment period, few side effects, and reduced scar formation. To the best of our knowledge, this is the first report on the treatment of acne conglobata with PDT., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The clean-shave haircut known locally as the chiskop is rare among females but popular with black South African men, who are also predisposed to folliculitis keloidalis nuchae (FKN) (keloids on the back of the head). During a previous study, participants described an unexpected symptom of haircut-associated bleeding. As this is not a widely recognised entity, we conducted the present study at an HIV clinic servicing the same population, with the objective of comparing the prevalences of haircut-associated bleeding and FKN in 390 HIV-positive subjects with published data for Langa (Western Cape, South Africa). The results for HIV-positive participants were similar to the population data, but in both groups the prevalence of haircut-associated bleeding (24.5% v. 32%; p=0.17) was much higher than that of FKN (10.2% v. 10.5%), suggesting that the hairstyle increases the risk of bleeding even in people with healthy scalps without folliculitis. This study does not (and was not intended to) prove a higher HIV prevalence in chiskop wearers or in FKN sufferers, but it confirms a history of haircut-associated bleeding in at least a quarter of our male study participants. The risk of transmission of blood-borne infection via haircuts is likely to be low, but requires formal quantification. Public education on adequate sterilisation of barber equipment between haircuts and promotion of individual hair-clipper ownership for chiskop clients should not be delayed. Depilatory creams formulated for African hair offer a non-mechanical means of achieving clean-shave hairstyles.

Background: Laser-assisted hair removal causes miniaturization of hair shafts which are the principal contributors to inflammation in acne keloidalis nuchae (AKN)., Objective: To assess the efficacy of hair reduction by long pulsed Nd-YAG laser as a therapeutic modality for AKN., Methods: This interventional pilot trial included 16 patients with AKN who received 5 sessions of long pulsed Nd-YAG laser. Lesions were objectively and subjectively assessed at the third and fifth laser sessions, and 1 year after. Global response to treatment was rated using a quartile grading scale regarding the percentage improvement in the count of papules and the size of the plaques. Biopsies were taken before and 2 weeks after the fifth session to evaluate the pathological changes associated with improvement of the treated lesions., Results: All patients showed a significant improvement. The percentage of improvement in the early caseswas significantly higher when compared to late cases.Two weeks after the fifth session, all biopsies showed a significant decrease in the inflammatory infiltrate except one case. Sclerosis was markedly decreased. Complete absence of hair follicles and adenexawas observed, apart from in 2 cases., Conclusion: Laser hair depilation can significantly improve this disfiguring chronic disorder. Starting treatment as early as possible achieves the best results and can stop the disease process if followed by maintenance sessions.

Keloid disease (KD) is a common fibroproliferative disorder of unknown aetiopathogenesis, with highly unsatisfactory treatment. Therefore, it is crucial to have a robust and clinically relevant model for studying KD pathobiology as well as preclinical testing of potential KD therapeutics. However, the unique occurrence of KD in human skin and the corresponding lack of animal models pose a major challenge in KD research. Therefore, we developed a simplified assay for the serum-free, long-term organ culture of KD tissue that facilitates quantitative analyses of major KD read-out parameters. Four millimetre KD punches embedded in a collagen matrix and organ-cultured at the epidermis air-liquid interphase (ALI) in supplemented William's E medium showed optimal tissue, cell and RNA preservation for up to 6 weeks (as measured by H & E and Pyronin Y histochemistry as well as by MTT assay, lactate dehydrogenase release and quantitative Ki67/TUNEL immunohistomorphometry). The keloid phenotype persisted well during this period, as shown by collagen-I and -III synthesis (Herovici's histochemistry staining and ELISA), and analysis of the expression of significant KD markers (CD3, CD20, CD31, CD34, CD56, tryptase, Langerin, vimentin, neutrophil elastase, CTGF and Collagen). To functionally evaluate whether this assay can test the response to candidate therapeutics, dexamethasone, a glucocorticosteroid often used in KD therapy, was administered. Indeed, dexamethasone significantly reduced the keloid volume and cellularity plus induced epidermal shrinkage. Therefore, this novel assay provides a quantitative, clinically relevant model system for studying KD pathobiology and response to treatment., (© 2012 John Wiley & Sons A/S.)

A 35-year-old African American man presented with complaints of malodorous drainage from hypertrophic lesions on his occipital scalp (Figure 1, inset). The patient had no family history of keloid formation and no other keloids on his body. The hypertrophic mass on his scalp had been present for 10 years and had not been a result of any type of mechanical, surgical, or laser treatment. It corresponded to the distribution of a large vascular malformation over the occiput (Figure 1). The vascular malformation extended from the occipital scalp to the right parietal scalp, the right side of the face, neck, upper chest, and right arm, with varicosities and hypertrophy of the right upper extremity (Figure 2). The vascular malformation over the right parietal scalp and ear was characterized by bleb formation and hypertrophy of the right ear. The patient reported that no manipulation, including laser treatment, of the vascular malformation had been previously performed. He did state that a previous dermatologist had attempted serial surgical excision of the cerebriform nodules but retired during the course of treatment. He stated that the appearance of his keloid formation and port-wine stain had not changed during the past 10 years. A previous biopsy of a hypertrophic lesion showed histologic findings consistent with folliculitis keloidalis nuchae. Cephalexin 500 mg 4 times daily for 14 days was prescribed for the purulent drainage. A Doppler ultrasound was ordered of the right upper extremity to evaluate for an arteriovenous malformation and showed no evidence of venous thrombosis or arteriovenous malformation. On a second visit 2 weeks later, the hypertrophic lesions continued to show drainage. Clindamycin gel to be applied twice daily to the scalp was added. The patient also had magnetic resonance imaging with and without gadolinium contrast (Figure 3) ordered, which showed a large hypertrophic giant scalp keloid overlying the occipital and suboccipital region measuring 12x 19 cm. There was soft tissue thickening involving the right external ear, extending inferior to the right ear, overlying an intact parotid gland. There was no evidence of muscular or skull invasion.

Background: Tumor necrosis factor-alpha (TNF-alpha) is a proinflammatory and profibrotic cytokine that inhibits degradation of collagen and glycosaminoglycans. Etanercept, a recombinant TNF-alpha receptor fusion protein, may decrease excessive fibrous tissue in keloids., Objective: To evaluate the tolerability and efficacy of etanercept as compared to triamcinolone acetonide (TAC) for the treatment of keloids., Methods: Twenty subjects were randomly assigned to receive monthly intralesional injections of either 25 mg of etanercept or 20 mg of TAC for 2 months. Keloids were evaluated at baseline, week 4, and week 8 by subjects and investigators in a blinded fashion using physical, clinical, and cosmetic parameters. Photographs were taken and adverse events were noted during each evaluation., Results: Etanercept improved 5/12 parameters including significant pruritus reduction, while TAC improved 11/12 parameters at week 8, although no statistical difference was observed as compared to baseline. There was no significant difference between the 2 treatment groups. Both treatments were safe and well tolerated., Conclusion: Etanercept was safe, well tolerated, improved several keloid parameters, and reduced pruritus to a greater degree than TAC therapy. However, further studies are required before it can be recommended for the treatment of keloids.

Keratosis follicularis spinulosa decalvans is a rare, X-linked disorder characterized by scarring alopecia of the scalp and eyebrows in the setting of widespread keratosis pilaris. Less frequent associations are ocular abnormalities and palmoplantar keratoderma. Acne keloidalis nuchae has previously been described in one patient with keratosis follicularis spinulosa decalvans. We report another case of keratosis follicularis spinulosa decalvans with acne keloidalis nuchae and tufted hair folliculitis, thus further establishing this association.

Acne keloidalis nuchae (AKN) is a chronic scarring folliculitis that presents clinically as follicular papules and pustules. These can coalesce into firm hypertrophic plaques and nodules on the nape of the neck, most commonly affecting young adult men. Treatment includes topical steroids/antibiotics and oral antibiotics, but often has disappointing results. Surgical approaches include excision with primary closure or skin grafting, and hair-removal lasers. Another surgical approach is excision with secondary intention healing. This can result in good cosmesis with little or no recurrence. We report two men with AKN where treatment by excision with secondary intention was successful.

Background: The prevalence of acne keloidalis nuchae (AKN), a chronic inflammatory process of the hair follicles resulting in keloidal papules and plaques at the nape of the neck, is increasing in our environment., Methods: A prospective hospital-based observational study was conducted at the adult medical dermatologic outpatient department of Irrua specialist teaching hospital, Edo State, Nigeria. All patients referred to the dermatology clinic with symptoms and signs of AKN were recruited., Results: Thirty patients presented to the adult dermatologic unit with AKN over a period of 22 months, giving a gross incidence of 9.4% of dermatologic consultations. The common etiologic factor was secondary to trauma from an electric razor whilst having a haircut, followed by spread of keloid from the beard area., Conclusions: Minimization of trauma during hair cutting or shaving and personalization of haircare instruments may reduce the recently increased incidence of this condition in our environment.

Acne keloidalis is characterized by firm skin-colored papules on the surface of the neck and scalp. We report a case of tinea capitis in 60-year-old female which mimicked acne keloidalis. The lesions resolved following oral antifungal medication.

Keloid scars are an idiopathic result of cuts, bruises, lacerations and often from surgical incisions. Medical therapy has been used with some results, but often surgical excision is necessary when the keloids are located in areas of exposed skin. Often skin grafting is necessary. The problem of keloid formation is more common in African Americans and Asians in the United States. Because surgery of these lesions is sometimes considered cosmetic by HMOs and other insurance carriers, there exists a dispute between the medical profession and insurance carriers regarding the medical necessity of surgery. We have operated on many keloids in our practice; however, the case report we are presenting is a unusual and rare case of giant keloid formation requiring extensive surgery and x-ray therapy.

Objective: To determine the efficacy of excision with primary closure in the treatment of extensive and refractory acne keloidalis nuchae (AKN)., Design: Intervention before-after trial. Duration of follow-up ranged from 1 to 5 years., Setting: University-based ambulatory outpatient dermatologic surgery unit., Patients: Referred sample of 25 patients with extensive AKN that was refractory to medical management. All patients were healthy, young black men who had no medical problems and were not taking any medications. No other eligible patients refused to be included in the study. All 25 patients completed the study., Interventions: All 25 patients underwent surgical excision of AKN. Twenty of the 25 underwent excision with layered closure in 1 stage. Four patients underwent 2-stage excisions with layered closure. One patient underwent excision with second-intention healing., Main Outcome Measure: A test of the following hypothesis: excision with primary closure is a successful treatment modality with little risk of recurrence for extensive cases of AKN., Results: The author and all 25 patients rated the cosmetic result of surgery as good to excellent. No patients experienced complete recurrence of their acne keloids. Fifteen patients developed tiny pustules and papules within the surgical scar. Five patients developed hypertrophic scars. Papules, pustules, and hypertrophic scars were all successfully treated with high-potency topical and intralesional steroids., Conclusions: Excision with primary closure is an excellent surgical treatment modality for the management of extensive cases of AKN. Extremely large lesions should be excised in multiple stages. The surgeon should carefully assess each patient to determine whether AKN should be excised in 1 or multiple stages.

Objective: To better define the pathogenesis of acne keloidalis (AK)., Design: Prospective, blinded study of histologic material collected from 10 patients with clinically typical AK., Setting: Outpatient dermatology clinic of a military tertiary care medical center., Patients: Ten male volunteers 18 years or older with early AK lesions (1- to 4-mm firm papules on the lower occipital/nuchal region)., Data Source: Biopsy specimens from small, early lesions and from clinically uninvolved skin, studied histologically with transverse sectioning., Intervention: Three separate 4-mm punch biopsy specimens of the scalp (lesional, perilesional, and "normal" scalp) were obtained from each volunteer. The specimens were processed using transverse sectioning., Main Outcome Measures: The primary variables for data analysis were the presence or absence of the following histologic features: premature loss of the inner root sheath; eccentric placement of shaft, with thinning of the outer root sheath; lamellar fibroplasia surrounding the follicle; loss of sebaceous glands; evidence of follicular destruction or scarring; inflammation; and intrafollicular or perifollicular microorganisms. The number and type of hairs were also recorded., Results: The most common findings in the 19 histologically abnormal specimens were perifollicular, chronic (lymphocytic and plasmacytic) inflammation, most intense at the level of the isthmus and lower infundibulum; lamellar fibroplasia, most marked at the level of the isthmus; complete disappearance of sebaceous glands, associated with inflamed or destroyed follicles; thinning of the follicular epithelium, most marked at the level of the isthmus; and total epithelial destruction (superficial and deep), with residual "naked" hair fragments. Even some "normal" specimens contained true follicular scars, demonstrating that normal-appearing scalp skin had previously been affected by the disease., Conclusions: Acne keloidalis is a primary form of scarring alopecia, and many of the histologic findings closely resemble those found in certain other forms of cicatricial alopecia. Extensive subclinical disease may be present in patients with AK and can account for some of the permanent hair loss. Overgrowth of microorganisms does not appear to play an important role in the pathogenesis of the disease. There is no etiologic relationship between AK and pseudofolliculitis barbae. Therapies found to be useful in other forms of inflammatory scarring alopecia are useful in the treatment of early AK.

Tufted folliculitis is an uncommon folliculitis of the scalp that resolves with patches of scarring alopecia within which multiple hair tufts emerge from dilated follicular orifices. The clinicohistological data from a group of 15 patients with tufted folliculitis were reviewed and compared with those of seven patients with folliculitis decalvans, five with acne keloidalis nuchae, four with dissecting cellulitis of the scalp, three with kerion celsi and 20 with follicular lichen planus. It was found that tufted folliculitis could be differentiated from folliculitis decalvans only by finding several hair tufts scattered within patches of scarring alopecia. Histologically, a single tuft consisted of peculiar clustering of adjacent follicular units opening at the bottom of an epidermal depression. Conversely, the presence of keloidal plaques in acne keloidalis nuchae, coalescing nodules discharging purulent material in dissecting cellulitis of the scalp, erythematous plaques covered by pustules replete with fungal elements in kerion celsi, and the absence of follicular pustules in follicular lichen planus distinguished these diseases from tufted folliculitis. On the basis of these findings, it is suggested that tufted folliculitis should be considered as a distinctive clinicohistological variant of folliculitis decalvans. Tufting of hair is caused by clustering of adjacent follicular units due to a fibrosing process and to retention of telogen hairs within the involved follicular units.

Acne keloidalis nuchae is a chronic, scarring folliculitis that affects mostly black patients and is located on the back of the neck of young adults. The course is progressive and leads to hypertrophic scarring, chronic abscesses and hair loss. We discuss the relationship between acne keloidalis and tufted hair folliculitis, pointing out the possibility that tufted hair folliculitis is not a specific disease but secondary to other progressive folliculitis like folliculitis decalvans, dissecting cellulitis or acne keloidalis.

Background: Acne keloidalis (AK) is an important cause of morbidity in Nigeria and accounts for 1.3% of patients with skin conditions in a Nigerian dermatology clinic. Treatment is usually unsatisfactory because the etiopathogenesis is unclear., Methods: A prospective clinico-pathological study was carried out to identify predisposing factors, viable treatment modalities, and prognostic indicators., Results: The study suggested that AK is associated with the male gender seborrheic constitution, early reproductive years, and increased fasting blood testosterone concentration. Features that may predispose to the vastly predominant occipital location of the lesions include increased mast cell density and dilatation of dermal capillaries., Management: The main aims are diagnosis of early papules and avoidance of physical and chemical traumatizing agents. Retinoic acid analogs and antiandrogens may be helpful., Conclusions: The widespread use of irritating physical and chemical traditional treatment remedies and delay in seeking medical attention--AK is typically asymptomatic--contribute to the relatively advanced nature of the disease at the time of presentation to the specialist.

A 26-year-old female developed a severe acneiform eruption on her face, chest and back soon after she started taking lithium carbonate for psychosis. Histopathological examination revealed it to be folliculitis, rather than true acne. The eruption continued for six months but was resolved three months after discontinuing the drug. It has not reappeared in the following 3 years.

A man developed acne keloidalis-like lesions in the scalp during treatment with diphenylhydantoin and carbamazepine for epilepsy. These drugs were suspected to play a role in the pathogenesis of this skin disease in an unusual location, based on clinical evidence and on the in vitro test, mast cell degranulation (MCD).

The earliest stages of acne keloidalis are not well characterized. In the present study, transverse sections of the early lesions revealed follicular units in several stages of inflammation. These follicles surrounded the central follicular units that gave rise to the clinically evident papule. Despite a spectrum of inflammatory changes, the most marked inflammation consistently occurred in the deep infundibular and isthmian levels of the hair follicles. Two follicles, presumably in the earliest stage, exhibited primarily an acute folliculitis and perifolliculitis, with destruction of the follicular wall and the release of hair. Central follicles showed predominantly acute neutrophilic or chronic lymphocytic inflammation at the upper isthmian levels and granulomatous inflammation at the deeper isthmian levels. Other follicles showed scar at the isthmian levels trapping hair fragments in the inferior portion of the follicle, with granulomatous inflammation and scarring. Sebaceous glands were absent in all stages of folliculitis in seven of eight follicular units.

Acne keloidalis is a chronic scarring folliculitis that most commonly occurs on the scalps of young black men. This disorder is described in two black women who had no evidence of androgen excess. Trauma to scalp hair may have precipitated the condition in one patient. Although it is uncommon, acne keloidalis should be considered a treatable cause of cicatricial alopecia in women.