Multimodality Surgical Treatment Approach to Acne Keloidalis Nuchae Based on Lesion Morphology

Acne keloidalis nuchae (AKN) correctly termed "folliculitis keloidalis", is an unusual form of chronic folliculitis and cicatricial alopecia that affects nape of neck. AKN can lead to significant scarring with tumor like masses and alopecia. Treatment in chronic cases is challenging with recurrence being common. Several modalities are being tried with variable success. We aim to report our experience with multimodality surgical approach. Five patients of chronic AKN refractory to intralesional steroids were treated between 2015 - 2018 with (1) excision and primary closure or (2) punch excision followed by healing with secondary intention or (3) intralesional cryotherapy, based on lesion morphology, site and extent . All patients also underwent long-pulsed (LP) neodymium-doped yttrium aluminum garnet (Nd:YAG)laser hair removal for the affected part with an aim to prevent new lesions from developing in the surrounding area. Patients were followed at regular intervals till 6 months. 100% patients were satisfied with the treatment outcome. They showed 80%-90% overall reduction in lesions with satisfactory cosmetic outcome. Complete removal of follicles leads to least chance of local recurrence. Surgical excision remains the most effective modality of management. In case of lesions <5 mm, punch excision can be gratifying. Cryotherapy is useful where excision and primary closure is not feasible. Hair removal lasers can prevent new lesions in the sorrounding area. Combined multimodality approach tailored to the type of lesions gives maximal result with a better cosmetic outcome.