Photo Rounds

Large, painful mass on neck

A 32-year-old Latino man presented to his family physician (FP) with a large, painful mass on his posterior neck that had grown over the past 3 years. The patient also had some hair loss in the area. He wondered if this was caused by the way a barber had cut his hair. He said he’d been wearing his hair longer because he was afraid of being cut on his neck.

What's your diagnosis?


The FP diagnosed acne keloidalis nuchae (AKN) based on the large keloidal mass with multiple hairs growing from single follicles. When multiple hairs grow from single follicles, this is called tufted folliculitis and is seen in various types of scarring alopecia.

The FP told the patient that the exact cause of AKN is unclear, but that it can occur in patients with tightly curled hair shafts and those whose posterior hairline is shaved with a razor. (For more on AKN, see last week’s case here.) The FP advised the patient to avoid short haircuts.

As far as treatment was concerned, the FP discussed the 2 best options: intralesional steroids and/or surgery. The major risks of intralesional steroids are pain at the time of injection and hypopigmentation of the skin at the site of injection weeks to months after the injection. Also, there is no guarantee that the steroid injection will work. As for surgery, the FP advised that there would be a significant risk of intraoperative bleeding and postoperative scarring; also, a plastic surgeon would need to be called in.

The patient was not interested in the surgery, and opted for the intralesional steroid injection, instead. The FP explained the risks and benefits of the procedure, got the patient’s written consent, and injected triamcinolone acetonide 10 mg/mL into the mass using a 25-gauge needle. This was difficult to do because the mass was firm. During a follow-up visit a month later, the FP noted that the mass was smaller. At the patient’s request, a second injection was performed. This one involved a stronger concentration: 40 mg/mL triamcinolone.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Pseudofolliculitis and acne keloidalis nuchae. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:665-670.

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