A Neglected Acne Scar Type: Papular Acne Scars and Their Correlations With Keloid Scars

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.

Acne keloidalis nuchae in Asian: A single institutional experience

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.

Keloid formation occurring in the distribution of a congenital vascular malformation

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.

Evaluating the tolerability and efficacy of etanercept compared to triamcinolone acetonide for the intralesional treatment of keloids

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 associated with acne keloidalis nuchae and tufted hair folliculitis

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.

Prevalence of acne keloidalis nuchae in Nigerians

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: A novel presentation for tinea capitis

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.

Folliculitis keloidis nuchae

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.

The surgical management of extensive cases of acne keloidalis nuchae

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.

Acne keloidalis is a form of primary scarring alopecia

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 of the scalp: a distinctive clinicohistological variant of folliculitis decalvans

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 and tufted hair folliculitis

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.

Clinical, biochemical and morphologic features of acne keloidalis in a black population

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.

Acneiform eruption induced by lithium carbonate

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.

Acne keloidalis-like lesions on the scalp associated with antiepileptic drugs

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).

Acne keloidalis. Transverse microscopy, immunohistochemistry, and electron microscopy

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 in women

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.

Acne keloidalis: a review

Acne keloidalis is a chronic scarring folliculitis located on the posterior neck of young black men. It is manifest clinically by follicular papules that coalesce into firm plaques and nodules. Examination of early lesions shows that inflammation begins at the deep infundibular and isthmic levels of the hair follicle and is accompanied by absence of sebaceous glands. The etiology of acne keloidalis is uncertain, but centers around anatomic, infectious, and autoimmune theories. Successful surgical therapy of advanced cases can be carried out using a number of methods as long as subfollicular destruction of the process is achieved.

Pseudofolliculitis barbae and related disorders

Pseudofolliculitis barbae, although not a serious medical problem, is certainly a distressing one for the affected patient. Its pathogenesis lies in an ingrown hair arising from the curved hair and follicle common in black men and women. Improper shaving techniques cause ingrown hairs through both transfollicular and extrafollicular mechanisms. Various treatment modalities exist, but there is no cure. Treatment must be individualized, as not all regimens will work for each patient. With diligence, pseudofolliculitis barbae can in many instances be controlled. Dermatitis papillaris capillitii is related to pseudofolliculitis barbae because its pathogenesis also lies in a curved hair and follicle. The treatment differs, however. Mild to moderately severe cases can be kept under good control with intralesional injections of steroid and a topical chloramphenicol and steroid cream mixture. Scarred or keloidal lesions may require surgery.

Acne keloidalis nuchae. A transepithelial elimination disorder

In four cases of acne keloidalis nuchae, varying stages of transepithelial elimination were observed histologically, suggesting that acne keloidalis represents a transepithelial elimination disorder akin to perforating folliculitis.

Acne keloidalis nuchae: report and treatment of a severe case

Acne keloidalis nuchae (folliculitis keloidalis or dermatitis papillaris capillitii) is a chronic, deep, scarring folliculitis of the nuchal area. Therapeutic measures such as oral and topical antibiotics, intralesional injections of fluorinated adrenocorticosteroids, and radiotherapy are sometimes effective in controlling this condition. A case of refractory acne keloidalis is presented to show the curative possibility of aggressive surgical therapy.

Acne keloidalis of the burned male face. Case report

Acne keloidalis is characterized by infected keloid-like nodules in the short-cut nuchal region probably caused by recurving, ingrowing hairshafts. A case with a deep, partial-thickness burn of the hair-bearing part of the face of a man is reported. After healing, the patient started shaving himself thus inducing a severe state of acne keloidalis. It seems advisable in males not to shave during the first eight eight to ten months after a partial-thickness burn of the face in order to avoid this troublesome condition.

[Autoradiographic investigations in actinic (senile) comedones (author's transl]

Skin specimens of patients suffering from actinic comedones, young patients with acne vulgaris, and normal controls of the same age groups respectively were subjected to in vitro autoradiography. From the results it can be concluded, that a rise in the proliferational activity in the follicular infundibulum due to actinic stimuli is responsible for the development and growth of actinic comedones.