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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 3  |  Page : 955-959

Acne keloidalis nuchae treatment


Department of Dermatology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission07-Jul-2020
Date of Decision22-Sep-2020
Date of Acceptance27-Sep-2020
Date of Web Publication18-Oct-2021

Correspondence Address:
Marwa H. E. Khalil
Desouk, Kafr El-Sheikh 33657
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_218_20

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  Abstract 


Objectives
To compare the efficacy of 1064-nm Nd : YAG laser and intralesional corticosteroid in the treatment of acne keloidalis nuchae (AKN).
Background
AKN is a chronic inflammatory condition that leads to scarring of the hair follicles, development of keloid-like papules and plaques, and scarring alopecia on the nape of the neck and occipital scalp.
Patients and methods
The study was conducted on 20 patients with AKN and was studied through the following regimens: group I included 10 patients treated by long pulsed Nd : YAG laser of 1064-nm wavelength, and group II comprised 10 patients treated by intralesional corticosteroid. Sessions were performed every 2 weeks for six sessions. Evaluation included papule count, keloidal plaque size assessment, and patient satisfaction before, at every session, and at the end of treatment.
Results
Patients' papule and pustule count in Nd : YAG group before treatment ranged between 3 and 30 (10.70±8.43), and after treatment, it was decreased significantly (3.70±3.37), whereas in intralesional corticosteroid group before treatment, it ranged between 2 and 9, and after treatment, it decreased significantly. There were no significant differences before treatment and after treatment, where P=0.218.
Conclusion
Treatment of AKN by Nd : YAG 1064-nm laser is much more promising than intralesional injection of corticosteroids and much more tolerated by patients.

Keywords: acne keloidalis nuchae, intralesional corticosteroid, laser, Nd : YAG 1064, and plaques


How to cite this article:
Hagag MM, Khalil MH. Acne keloidalis nuchae treatment. Menoufia Med J 2021;34:955-9

How to cite this URL:
Hagag MM, Khalil MH. Acne keloidalis nuchae treatment. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:955-9. Available from: http://www.mmj.eg.net/text.asp?2021/34/3/955/328318




  Introduction Top


Acne keloidalis nuchae (AKN) is a chronic inflammatory condition characterized by scarring folliculitis involving the hair follicles of the nape of the neck [1]. It is clinically presented by multiple papules and pustules which enlarge forming confluent thickened keloid-like plaque arranged in irregularly linear groups just below the hairline [2]. The condition occurs mainly in postpubescent males between the ages of 14 and 25 years; however, a few female patients have also been reported [1]. AKN occurs most frequently in individuals of African descent [3]. The cause of AKN remains unclear; however, penetration of cut curved hairs into the skin in genetically predisposed individuals is the most accepted theory [4]. The notice that AKN lesions are caused by ingrowing hair is analogous to the situation in pseudofolliculitis barbae [5]. Unfortunately, the disease is often refractory, with reported recurrence. It persists for many years as new papules continue to form at intervals, and they heal leaving behind hypertrophic or keloidal papules [6]. Numerous modalities have been used with varying degrees of success. Although papulopustular lesions may respond to topical or intralesional steroids and to topical retinoids, antibiotics, and immune modulators, larger plaques require surgical excision [7]. Based on the theory that the AKN pathogenesis is similar to that of pseudofolliculitis barbae, an 810-nm diode laser, a 1064-nm Nd : YAG laser, and a 755-nm alexandrite laser have been suggested as an effective alternative therapy for AKN [8]. It causes coagulation necrosis of the hair follicles and the fragmented hair shafts in the deep dermis, which are the main cause of inflammation in AKN, thus stopping its further progression [9].

This study aimed to compare the outcome of treatment of AKN using Nd : YAG laser and intralesional injection of triamcinolone acetonide 40 mg/ml.


  Patients and methods Top


The study was conducted on 20 patients with AKN. All participants signed a written informed consent with explaining the aim of study before the study initiation. Approval of the study protocol was obtained by the Ethics Scientific Committee of Menoufia University Hospital. These patients were studied through the following regimens: group I included 10 male patients who were treated by six sessions of long pulsed Nd : YAG laser 1064 nm (Fotona Stegne 7, 1000 Ljubljana, Slovenia, EU) using the following parameters: fluence in the range of 200 : 260 J/cm2 and 25 ms pulse duration. Between sessions, patients used Dermovat cream once daily as local anti-inflammatory agent, not as part of the treatment procedure. It is used to decrease burning and itching after laser and between sessions. Anesthetic cream was used 30 min before the session. Cleaning of diseased area was done by 70% alcohol before starting the session. Both patient and the doctor wore protective goggles on their eyes during the session.

Group II included 10 male patients who were treated by intralesional injection of triamcinolone acetonide 40 mg/ml in 1 : 1 dilution with normal saline. We used insulin syringe containing 0.5 ml of triamcinolone acetonide 40 mg/ml and 0.5 ml saline for injection inside the lesions, keloid, and papules. In subsequent sessions after shrinkage of lesions' size and decrease in pliability, we used 1 : 2 dilution of 0.3 ml triamcinolone acetonide 40 mg/ml and 0.7 ml of saline. Before treatment by intralesional injection of corticosteroids, cleaning of the diseased area by 70% alcohol is done before starting the session.

Clinical history included age, sex, duration of the disease, and previous treatment for the disease either local or systemic or interventional. Complete physical examination included type of skin, papules count, keloidal plaque size and pliability, and signs of local infections. Consent for treatment and enrollment in the study was taken from every patient after discussing with him the options of the treatment and explaining that he was being enrolled in this study. Exclusion criteria included current use of isotretinoin, previous laser therapy, contraindication to the use of corticosteroids, vitiligo, presence of signs of local skin infection, presence of skin wound, and development of adverse effect to treatment. Evaluation procedures were clinical assessment and photographic documentation with digital camera before starting of the treatment and repeated each session until the end of the treatment. Patients were asked to report any adverse effect. Evaluation was done at baseline and every two sessions till the sixth session. Follow-up was carried on for 3 months. All patients were asked to grade the overall percentage satisfaction with treatment 1 month after the sixth session.


  Results Top


Patients' symptoms of pruritus and bleeding in Nd : YAG group before treatment showed that five (50%) had moderate symptom, four (40%) had severe symptoms, and only one (10%) had severe symptom, whereas after treatment, six (60%) had very mild symptoms and four (40%) had mild symptoms with statistically significant differences between before and after treatment. However, in intralesional corticosteroid group before treatment, two (20%) had mild symptoms, six (60%) had moderate symptom, one (10%) had severe symptoms, and one (10%) were severe, whereas after treatment, one (10%) patient had very mild symptoms, seven (70%) had mild, and two (20%) had moderate, with statistically significant differences between before and after treatment results. There were no statistically significant differences between the two groups before treatment and after treatment [Table 1]. Patients' plaque size in Nd : YAG group before treatment ranged between 0 and 30, with a mean value of 9.70 ± 8.37, and after treatment, it decreased significantly, with a mean value of 3.50 ± 2.51, and the mean percentage of change was 60.93 ± 17.54, whereas in intralesional corticosteroid group, before treatment, it ranged between 2 and 9, with a mean value of 4.40 ± 2.41, and after treatment, it decreased significantly, with a mean value 2.0 ± 1.05, and the mean percentage of change was 53.74 ± 11.05. There were statistically significant differences between the two groups before treatment, where P = 0.035, whereas there were no statistically significant differences between the two groups after treatment, where P = 0.218 [Table 2]. Patients' papule and pustule count in Nd : YAG group before treatment ranged between 3 and 30, with a mean value of 10.70 ± 8.43, and after treatment, it decreased significantly, with a mean value of 3.70 ± 3.37, and the mean percentage of change was 68.58 ± 22.21. However, in intralesional corticosteroid group, before treatment, it ranged between 2 and 9, with a mean value of 6.70 ± 2.45, and after treatment, it decreased significantly, with a mean value 3.30 ± 2.06, and the mean percentage of change was 51.32 ± 17.22. There were no statistically significant differences between the two groups before treatment and after treatment, with P = 0.218 [Table 3]. Patient's satisfaction after treatment in Nd : YAG group ranged between 60 and 90, with a mean value of 74.50 ± 8.32, whereas in intralesional corticosteroid group, it ranged between 40 and 70, with a mean value of 56.0 ± 10.49, with statistically significant differences between the two groups, where P value less than 0.001 [Table 4].
Table 1: Comparison between the two studied groups according to symptoms (pruritus and bleeding)

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Table 2: Comparison between the two studied groups according to plaque size

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Table 3: Comparison between the two studied groups according to papule and pustule count

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Table 4: Comparison between the two studied groups according to patient satisfaction after treatment

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  Discussion Top


The term AKN is somewhat a misnomer because the lesions do not occur as a result of acne vulgaris but rather a folliculitis. Moreover, the lesions do not have histological features suggestive of keloids nor do the affected patients tend to develop keloids in other areas of the body [10]. AKN occurs majorly in those of African descent. It has been reported in a few white patients and other ethnic groups. It is predominantly a disorder of postpubescent males between the age of 14 and 25 years, although there are a few reports in females, with a male to female ratio of 20 : 1 [11]. The studied groups were subjected to clinical examination with attention to type of skin, papules count, keloidal plaque size, keloidal plaque pliability, and signs of local infections. Clinical assessments and photographic documentation with digital camera were conducted before treatment and repeated each session until the end of the treatment. Regarding pruritus and bleeding, there were no statistically significant differences between the two groups before treatment and after treatment. In the study by Zeid et al. [12], the pain score significantly decreased at the fifth laser session when compared with the first session (P = 0.005). The tenderness scores significantly decreased at the third and fifth sessions versus baseline (P < 0.001). Regarding plaque size, there were statistically significant differences between the two groups before treatment, where P = 0.035, whereas there were no statistically significant differences between the two group after treatment, where P = 0.218. Gamil et al. [13] reported that eight plaques were detected in five (33.3%) patients, which nonsignificantly decreased after therapy to two plaques in two (13.3%) patients. However, there was a significant decrease in plaque size, which decreased from 3.33 ± 0.96 to 1.5 ± 0, with a mean improvement of 90%. In Zeid et al. [12], all 16 patients received five sessions (4 weeks apart) of long pulsed Nd : YAG laser-assisted hair removal on the affected area, emitting 1064 nm, with a fluence of 35–45 J/cm2 and pulse duration 10–30 ms adjusted to skin type and hair thickness. Laser was applied to all papules and plaques. They demonstrated a significant decrease in the plaque count in all patients at the third and fifth laser sessions when compared with baseline values (P = 0.011 and 0.008, respectively). There was a significant reduction in plaque size in the third and fifth sessions compared with baseline values (P<0.001) and with a mean of 84% improvement. This decrease in plaque size was significantly detected in the fifth session when compared with the third session. The papule and pustule count in Nd : YAG group before treatment ranged between 3 and 30, with a mean value of 10.70 ± 8.43, and after treatment, it decreased significantly, with a mean value of 3.70 ± 3.37, and the mean percentage of change of 68.58 ± 22.21%. Similarly, Gamil et al. [13] reported that after laser therapy, there was a significant decrease in the mean papule count in the Nd : YAG group (P < 0.005). It decreased from 26.69 ± 22.32 to 7 ± 5.09, with a mean improvement of 88%. Zeid et al. [12] also demonstrated a significant decrease in the papule count in all patients at the third and fifth laser sessions compared with baseline values (P = 0.029), whereas in intralesional corticosteroid group, before treatment, it ranged between 2 and 9, with a mean value of 6.70 ± 2.45, and after treatment, it decreased significantly, with a mean value of 3.30 ± 2.06, and the mean percentage of change was 51.32 ± 17.22. There were no statistically significant differences between the two groups before treatment and after treatment, where P = 0.218. In our study, all patients were asked to grade the overall percentage satisfaction with treatment 1 month after the sixth session. The percentage satisfaction scale simply asked each patient whether they were very satisfied, satisfied, or not satisfied with the degree of lesion regression by comparing pretreatment and posttreatment photographs of the lesions, as well as symptom alleviation such as pain and pruritus. Patients' satisfaction after treatment in Nd : YAG group ranged between 60 and 90%, with a mean value of 74.50 ± 8.32%, whereas in intralesional corticosteroid group, it ranged between 40 and 70%, with a mean value of 56.0 ± 10.49%, with statistically significant differences between the two groups, where P value less than 0.001. In the study by Zeid et al. [12], patients' satisfaction was recorded in 93% of patients regarding the treatment procedure, as laser application was relatively tolerable compared with painful intralesional injections. Woo et al. [14] conducted a randomized controlled trial on 13 patients. 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 (0–10). They reported that the laser-treated side showed greater improvement in global assessment score. The mean decrease was 49.2% on the treated side and 32.8% on the control side (P = 0.144). Papules responded well to laser treatment, whereas 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 decrease was 59.3% for the treated side and 29.5% for the control side, P = 0.031). Our results on Nd : YAG laser therapy are consistent with those reported by Attia et al. [15], with 90.9% reduction in papule count and 70.4% reduction in plaque size in 25 patients with AKN. Dragoni et al. [6] showed that a 1064 nm Nd : YAG laser with 101–120 J/cm2 fluence used for four sessions led to a significant improvement in scarring that was clinically apparent.


  Conclusion Top


Intralesional corticosteroid injection was and is still used in the treatment of AKN. It is cheaper than Nd : YAG 1064-nm laser. In addition, keloid size decreases fast, but new lesions recur again and inflammatory papules and pustules start again. The use of Nd : YAG 1064-nm laser is much more promising than intralesional injection of corticosteroids and much more tolerated by patients with less adverse effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Zeid OM, Hosni HN. The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study. Eur J Dermatol 2012; 22:645–650.  Back to cited text no. 12
    
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Gamil HD, Khater EM, Khattab FM, Khalil MA. Successful treatment of acne keloidalis nuchae with erbium: YAG laser: a comparative study. J Cosmet Laser Therapy 2018; 20:419–423.  Back to cited text no. 13
    
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Woo D, Treyger G, Henderson M, Huggins R, Jackson-Richards D, Hamzavi I. Prospective controlled trial for the treatment of acne keloidalis nuchae with a long-pulsed neodymium-doped yttrium-aluminum-garnet laser. J Cutan Med Surg 2018; 22:236–238.  Back to cited text no. 14
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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