Author Bio: Dr. Sanusi Umar MD is the author of this article.
For certain patient cases, the long-term resolution of Acne Keloidalis Nuchae bumps can be achieved with laser. Dr.U notes that a common factor for the successful, long-term treatment of AKN is the elimination of hair within the lesion tissue which is usually the trigger which offsets the prolonged inflammation of the follicles. This results in the formation of folliculocentric lesions. However, while there are many studies which document general favorable results overall, they also discuss that the quality of outcomes typically varies across individuals which necessitates a standardized system of scoring and classifying specific manifestations of Acne Keloidalis Nuchae.
Dr.U has developed a groundbreaking patient selection criteria described in his JAAD publication, Selection criteria and techniques for improved cosmesis and predictable outcomes in laser hair removal treatment of acne keloidalis nuchae,
It serves two primary purposes in the treatment of AKN. First, it defines which patient cases can benefit from successful outcomes through laser treatment. Secondly, it provides a classification system which enables patients to achieve the most optimal results, while establishing realistic expectations.
Brief Summary on How Laser Works to Treat Acne Keloidalis Nuchae Bumps
Laser energy is absorbed by the pigmentation in the hair shaft which serves as its point of entry. It then proceeds to cause destruction to the hair follicle so that it can no longer produce hair and trigger the immune system’s inflammatory processes.
Dr.U’s Patient Selection Criteria for AKN Treatment With Laser
Dr.U recommends the use of laser to treat the following types of folliculocentric lesions.
- discrete bumps
- follicular bumps which have coalesced into bigger plaques
More advanced stage plaques which have developed smooth bald regions are not likely to benefit from AKN laser treatment. Removal through surgical excision should be considered instead.
Types of Discrete AKN Bumps Which Can Be Treated With Laser
In his JAAD publication, Dr. U defines the types of smaller AKN bumps (i.e. papules or nodules) which ideally qualify for laser treatment. He specifies that these discrete, individual lesions should have a vertical height of 2-3mm above the skin’s surface. Below the skin’s surface, most hair follicles are about 2-4mm long. Thus the total vertical axis then ranges from 4-7mm as it includes both the bump and the hair follicle which underlies it.
This resulting metric is quite significant since the Nd-YAG laser is able to penetrate a tissue depth of 5-7mm. Selecting bumps smaller than 3mm would then enable the laser to penetrate the entire length of the hair follicle.
Dr.U points out only applying the laser to just the bumps will create sporadic regions of patchy hair loss, surrounded by areas of hair growth. To prevent this, Dr.U has developed a classification system consisting of four types of AKN manifestations which can be treated with laser. Each type is characterized by the degree of spread, respective to the occipital notch. And for each one, Dr.U has outlined proposed zones for laser application which not only targets the individual AKN bumps but also creates an overall hairless region in the lower part of the scalp. These laser treatment schemas serve two important purposes for final patient results.
They redefine the posterior hairline above its original border to create a more natural and inconspicuous looking outcome
They address neighboring hair follicles which could potentially become sources of new AKN lesions, as the skin condition propagates.
Dr.U’s patient selection criteria, along with his classification system for laser treatment help qualified individuals achieve far better long-term outcomes. Using laser to treat entire zones, rather than individual bumps may raise the posterior hairline. But it also guarantees a more cohesive form of hair coverage, rather than one marked by empty gaps in the lower part of the scalp. And secondly, as noted, it addresses the comprehensive set of hair follicles within the treatment zone to prevent chances of future AKN recurrence.
Diagram of Dr. U’s AKN manifestations for laser treatment. In level 1, the bumps are below the halfway line. In level 2, the bumps extend above the halfway line
The Benefits of the Nd:YAG Laser For AKN Treatment With Laser
Since AKN tissue has already been affected by inflammation, it is more susceptible to experiencing burns inflicted by laser.
Although there are various types of long-pulse lasers which can be used for the treatment of AKN bumps, Dr.U prefers the use of the Nd:YAG laser.
For example, the Alexandrite 755nm can be used. Also, the Diode 800nm laser is another option. Both can penetrate an average depth range of 2-4mm which is the length of most hair follicles.
However, since the vertical length of the AKN lesional bump (above the skin) also needs to be considered, an even longer wavelength is needed.
The Nd:YAG laser is able to penetrate 5-7mm of tissue, which covers both the AKN bump lesion as well as the length of underlying hair follicles. Also it has a better safety profile since it is not absorbed by melanin as readily as the other two choices. It will produce a much smaller risk of burning the skin, which is especially important for black patients.
Dr.U’s Recommendations for AKN Laser Treatment
The very first step of Dr.U’s process for treating Acne Keloidalis Nuchae with laser is to classify the patient’s case. During the session, the designated zone is first shaved. A topical anesthetic is then administered.
After a waiting period of 15 minutes, laser energy is applied to the treatment area. As noted earlier, this would include both the lesions and non-lesional areas where hair growth is present.
In some individuals, the skin color may be dark. This may be due to the patient’s own genetics and natural skin tone. Or it may due to pigmentation which developed in reaction to the inflammation which occurred as a result of the AKN.
As an interesting note, laser energy tends to be absorbed by dark coloration, whether it is from the hair or skin. If the skin in the treatment area is dark, this may make it difficult for the laser to discriminate between the hair and the skin. And the targeting of the hair shafts can be more inaccurate as a result. Also, excessive absorption of laser energy in darker skin areas can also incur burns. Dr. U recommends lightening the area using 4% hydroquinone twice a day to help overcome these issues.
Dr.U also advises waiting about six months following the first session to see if lesions recur. If there is no development of new lesions, a treatment plan of at least four additional sessions (spaced at 6-8 weeks apart) is advised in order to achieve the best long-term results possible.
JAAD Publishes Dr.U’s Real Life Examples of Successful AKN Laser Treatment Outcomes
Dr. U’s JAAD publication discusses not only his patient selection criteria and treatment zone classifications, but it also includes three real-life examples which illustrate the effectiveness of his approach to AKN treatment using laser.
Laser Treatment Helps 52 Year Old Black Male AKN Patient Gets Rid of Bumps Once and For All
A middle-aged patient of African heritage came to Dr.U with follicular bumps that were vertically smaller than 3mm. They were located below the halfway boundary between the occipital notch and posterior hairline. His condition was therefore categorized at Level 1 within Dr.U’s classification system for laser treatment, which is based on severity.
Topical medications and steroid injections did not help him. Level 1 patients are given two choices for the shape of their new posterior hairline, following laser treatment.
This gentleman chose sharp lateral corners. For his case, four sessions using the Nd:YAG laser were administered. They were scheduled 6-8 weeks apart. At the end of his treatment series, he was able to experience the permanent resolution of all his AKN lesional bumps.
Laser Permanently Eliminates AKN Bump Lesions For Asian American Man
The second case example presented in Dr. U’s publication also involved a patient who qualified for AKN treatment with laser since his follicular papules were measured at less than 3mm in vertical height from the skin.
However, unlike the last example where the lesional bumps were present below the halfway line between the occipital notch and the posterior hairline, the papules resided above this line. Thus, this case was categorized as Level II within Dr.U’s classification system of AKN severity for patients who qualify for laser treatment.
In this instance, the patient required 5 treatments using the Nd:YAG laser. These were spaced at 6-8 weeks apart. Not only did this result in the permanent and complete resolution of his bumps, but also an inconspicuous posterior hairline that resembled the natural progression of retrograde alopecia. The patient chose this outcome as opposed to treating only the affected bumps which would have produced a patchy result.
Young African American Male Overcomes AKN Bumps Through Laser Treatment
The last and final case example features a 24 year old black male with AKN bumps smaller than 3mm in vertical height. His presentation was considered to be Level III within Dr.U’s laser treatment classification system. The spread of his bumps extended above the occipital notch in the upper part of his scalp. However, he only required two treatment sessions of Nd:YAG laser, each scheduled 6-8 weeks apart. The patient’s lesions resolved significantly, leaving a zone of hair thinning within the treatment area. For styling purposes, he preferred the outcome of having sparse hair versus total baldness in order to sport a tight crew cut.
One of the primary benefits of choosing laser treatment for smaller, earlier stage Acne Keloidalis Nuchae bumps is that it does not leave a scar. And secondly, if the spread of the bumps is expansive, beyond the occipital notch, towards the top of the head laser would be able to offer a more viable treatment approach compared to surgical excision.
To benefit on a permanent and long-term basis from the use of laser, individual patient cases can qualify for this form of AKN therapy if the individual papules are less than 3mm. Once selected, specific levels of severity can benefit from predictable aesthetic outcomes by applying specific treatment zones for the laser.
Frequently Asked Questions
1. Although a main advantage of using laser for AKN is the lack of wounding and linear scarring what is considered a downside to this form of treatment?
Laser treatment for AKN uses energy which can potentially cause burning to the skin, especially in cases where there is dark pigmentation. It is important to choose a wavelength that is more resistant to being absorbed by melanin and carefully select the parameters to be used for individual patients. The use of hydroquinone cream may also be considered in appropriate cases.
2. How can AKN laser treatments be managed to avoid complete baldness for more severe cases, if the patient wishes to maintain some hair growth?
It is possible for these types of patients to undergo a fewer number of laser treatments in order to treat their existing lesion bumps while maintaining some hair.
3. Although the Nd:YAG laser for AKN treatment has a high safety profile, are there still risks that patients should be aware of?
As discussed above, the 1064nm laser wavelength of the Nd:YAG laser is not as easily absorbed by melanin. And with its application, the risk of skin burns is more minimal, though not obsolete. Other measures can be taken, including using lower settings of energy, longer pulse durations, avoiding double pulsing and precooling the skin. Patients should also visit their provider on an ongoing basis for at least 24 weeks (6 months).