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Folliculitis Keloidalis

Clinical Presentation (1, 2, 3, 4, 5)

Folliculitis (Acne) Keloidalis (FK) is a mixed cell chronic primary scarring alopecia.  It presents with small, smooth, firm bumps with occasional pus on the posterior scalp and nape of the neck.  Over time lesions result in scarring hair loss and keloid scars

Epidemiology (6, 7, 8)

FK is most common in men of African descent age 20-50 years, although it can also occur in women.  The prevalence is estimated to be between <1%-9%.

Causes (1, 8)

The exact cause of folliculitis keloidalis is unknown.  Some associated factors include hair grooming (e.g., close shaves), trauma, friction (e.g., rubbing from high shirt collars or helmets), heat, humidity, infections (skin bacteria or skin mites- Demodex), and androgen hormones.

Diagnosis (1, 5)

TA is diagnosed via history, clinical scalp exam, and dermoscopic evaluation. Occasionally bacterial culture may also be done to rule out bacterial infection.

Treatment Options (1, 3, 9, 10, 11)

Depending on the extent of disease it may be difficult to return to normal scalp. Hair regrowth is NOT possible after the follicles are replaced by scar tissue.

  • Hair grooming/ Prevention: Avoid close shaving, frequent haircuts, and anything that may rub/ irritate the scalp (shirts with high collars, helmets, chains, etc.)

  • Anti-Inflammatory: Steroids (oral, topical/ injection), topical calcineurin inhibitors (tacrolimus and pimecrolimus),

  • Antimicrobials: Benzoyl peroxide, chlorhexidine, oral antibiotics (minocycline, doxycycline, erythromycin), topical antibiotics (clindamycin, erythromycin)

  • Keratolytics (promotes skin exfoliation): Salicylic acid, retinoids (topical and oral)

  • Destruction: Cryotherapy (Liquid nitrogen to individual lesions), laser (1064 nm NG: YAG, 810 nm Diode, 755 nm Alexandrite, CO2), and surgery