Acne Keloidalis Nuchae in the Armed Forces
Acne keloidalis nuchae (AKN) is a chronic inflammatory skin disease characterized by the development of keloidlike papules, pustules, and plaques on the occipital scalp and posterior neck following mechanical trauma and irritation. First-line therapy involves avoidance of aggravating factors including short and frequent haircuts. Medical treatments—from topical and intralesional steroids, oral antibiotics, and UV light to laser and surgical excision—have demonstrated varying degrees of efficacy. The active-duty military population faces unique challenges in the treatment of AKN because personal appearance and grooming standards restrict avoidance of the very factors that promote this disease process. In this population, early identification and treatment are critical to reducing overall patient morbidity and ensuring continued operational and medical readiness. This article reviews the clinical features, epidemiology, and treatments available in the management of AKN, with a special focus on the active-duty military population.
Practice Points
- Acne keloidalis nuchae (AKN) is a chronic inflammatory disorder of the occipital scalp and posterior neck characterized by keloidlike papules, pustules, and plaques that develop following mechanical irritation.
- Military members are required to maintain short haircuts and may be disproportionately affected by AKN.
- In the military population, early identification and treatment, which includes topical steroids, oral antibiotics, UV light therapy, lasers, and surgical excision, can prevent further scarring, permanent hair loss, and disfigurement from AKN.
Acne keloidalis nuchae that is severe enough to interfere with the proper use and wear of military equipment (eg, Kevlar helmets) or maintenance of regulation grooming standards does not meet military admission standards.10,11 However, mild undiagnosed cases may be overlooked during entrance physical examinations, while many servicemembers develop AKN after entering the military.10 For these individuals, long-term avoidance of haircuts is not a realistic or obtainable therapeutic option.
Treatment
Topical Therapy
Early mild to moderate cases of AKN—papules less than 3 mm, no nodules present—may be treated with potent topical steroids. Studies have shown 2-week alternating cycles of high-potency topical steroids (2 weeks of twice-daily application followed by 2 weeks without application) for 8 to 12 weeks to be effective in reducing AKN lesions.8,12 Topical clindamycin also may be added and has demonstrated efficacy particularly when pustules are present.7,8
Intralesional Steroids
For moderate cases of AKN—papules more than 3 mm, plaques, and nodules—intralesional steroid injections may be considered. Triamcinolone may be used at a dose of 5 to 40 mg/mL administered at 4-week intervals.7 More concentrated doses will produce faster responses but also carry the known risk of side effects such as hypopigmentation in darker-skinned individuals and skin atrophy.
Systemic Therapy
Systemic therapy with oral antibiotics may be warranted as an adjunct to mild to moderate cases of AKN or in cases with clear evidence of secondary infection. Long-term tetracycline antibiotics, such as minocycline and doxycycline, may be used concurrently with topical and/or intralesional steroids.6,7 Their antibacterial and anti-inflammatory effects are useful in controlling secondary infections and reducing overall chronic inflammation.
When selecting an appropriate antibiotic for long-term use in active-duty military patients, it is important to consider their effects on duty status. Doxycycline is preferred for active-duty servicemembers because it is not duty limiting or medically disqualifying.10,13-15 However, minocycline, is restricted for use in aviators and aircrew members due to the risk for central nervous system side effects, which may include light-headedness, dizziness, and vertigo.
UV Light Therapy
UV radiation has known anti-inflammatory, immunosuppressive, and antifibrotic effects and commonly is used in the treatment of many dermatologic conditions.16 Within the last decade, targeted UVB (tUVB) radiation has shown promise as an effective alternative therapy for AKN. In 2014, Okoye et al16 conducted a prospective, randomized, split-scalp study in 11 patients with AKN. Each patient underwent treatment with a tUVB device (with peaks at 303 and 313 nm) to a randomly selected side of the scalp 3 times weekly for 16 weeks. Significant reductions in lesion count were seen on the treated side after 8 (P=.03) and 16 weeks (P=.04), with no change noted on the control side. Aside from objective lesion counts, patients completed questionnaires (n=6) regarding their treatment outcomes. Notably, 83.3% (5/6) reported marked improvement in their condition. Aside from mild transient burning and erythema of the treated area, no serious side effects were reported.16
Targeted UVB phototherapy has limited utility in an operational setting due to accessibility and operational tempo. Phototherapy units typically are available only at commands in close proximity to large medical treatment facilities. Further, the vast majority of servicemembers have duty hours that are not amenable to multiple treatment sessions per week for several months. For servicemembers in administrative roles or serving in garrison or shore billets, tUVB or narrowband UV phototherapy may be viable treatment options.
