Photo Rounds

Enlarging scalp plaque

A 32-year-old Hispanic man sought care for an enlarging pruritic plaque on his posterior scalp of 3 years’ duration. Visual inspection revealed scarring and alopecia. There were also 2- to 3-mm firm papules, centered on hair follicles, that were peripheral to the main plaque. The patient had tried oral antibiotics and salicylic acid shampoo without improvement.

What is your diagnosis?



Scalp plaque

The findings of follicular-based papules, pustules, and scars led to the diagnosis of folliculitis keloidalis nuchae.

Follicular keloidalis, also called acne keloidalis nuchae, is more common in patients with darker skin types (Fitzpatrick skin types IV-VI). The pathogenesis is unclear, but the condition may arise from mechanical occlusion with a retained short hair that leads to follicular destruction. It also may be a primary disorder arising from bacterial infection and subsequent vigorous inflammation.

In the earliest stages, when only small inflammatory papules are present, patients should be instructed not to cut their hair shorter than 0.25-in long to avoid hair retention. Also, topical clindamycin lotion or topical chlorhexidine solution may serve as sufficient treatment. As the disease progresses, oral doxycycline 100 mg bid, combination rifampin 300 mg bid and clindamycin 300 mg bid for 3 months, or isotretinoin 1 mg/kg daily for 6 to 8 months are medical therapeutic options. Procedural options include radiation and laser hair removal.

In this patient, trials of intralesional triamcinolone acetonide 10 mg/mL helped to flatten the plaque, but hair loss persisted. Ultimately, he was referred to Plastic Surgery for excision and was treated for several months with doxycycline 100 mg bid and monitored for recurrence.

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

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