Author Bio: Dr. Sanusi Umar MD is the author of this article.
Last Updated on December 17, 2020 by Dr Sanusi Umar MD
Acne Keloidalis Nuchae (AKN) is a disfiguring, painful skin disease that causes scarring and irritation of the scalp. AKN causes hair follicles to become inflamed and develop bumpy lumps and scars. It often manifests as bumps and lumps on the back of the head or neck. However it presents, the condition is persistent and worsening with time. It afflicts young men of color and is far rarer in women.
Typically the first time the patient would hear the term “acne keloidalis nuchae or AKN” is when the consult a dermatologist. Many patients would make the connection with instances of head shaving, hence resort to calling it “razor bumps”, even “barber’s rash” on the back of the head or neck. The typical location of acne keloidalis nuchae is the nape area of the scalp and neck. However, in severe cases this condition can be widespread and affect the entire scalp surface.
Is The Name Acne Keloidalis Nuchae Accurate?
Acne keloidalis nuchae was first documented in the 1800s. The name, now considered a misnomer derived for the following reasons:
- Acne: Because of the manifestation of pimply lesions that sometimes discharge pus
- Keloidalis: Because of the potential for the lesion to grow into a mass consisting of scar tissue
- Nuchae: Because the lesions are typically located in the nape (nuchal) area (nape)
The only accurate name derivation is the nuchae part. We now know that these bumps on the back of the head are neither a case of acne nor a keloid. Despite this understanding the misleading name “acne keloidalis nuchae” has been retained by the scientific community for historical reasons, Other less commonly used medical terms exist, such as dermatitis papillaris capillitii, folliculitis keloidalis, sycosis nuchae, sycosis frambesiform, and keloidal folliculitis.
What are the Manifestations of Acne Keloidalis Nuchae or AKN?
The patient would typically report any one or a combination of the following signs and symptoms:
- Pimply bumps on the back of the head and neck
- A back of head bump that has multiplied, grown, or coalesced into a large, flat lesion
- Tumor-like growth that appears similar to a keloid
- Discharge of pus or blood
- Malodorous smell
Wondering if the bumps on the back of your head are the symptoms of AKN? Schedule a free consultation with Dr. Umar to learn more:
The symptoms of acne keloidalis nuchae typically form what looks like razor bumps on the back of the head and neck. However, these symptoms can spread over the entire posterior and occipital scalp if they continue to go untreated. Additionally, the physical symptoms that manifest with the onset of AKN can trigger some psychological symptoms and effects. Individuals who develop AKN can experience psychological impacts including:
- Loss of self confidence
These symptoms, much like the physical symptoms of acne keloidalis nuchae, can worsen over time if a patient goes undiagnosed and untreated.
Dr. Umar developed a classification system that recognizes the different manifestations of the varying types of lesion forms, as well as the different areas and sizes of AKN (meaning distribution of bumps on the back of the head and neck). This “barber’s rash” on the back of the head and neck is technically referred to as papules (less than 1cm in diameter), nodules (more than 1cm in diameter), merged papules and nodules, keloids or tumor-like masses, or a flat plaque. Each of these differing types of lesions vary in how they are distributed across the scalp ranging from stage one to stage four in size and distribution as seen in the chart below.
What Causes Acne Keloidalis Nuchae Bumps On The Back Of The Head To Form?
The exact causes of AKN are not clear. Many medical experts still debate how, exactly, this lump on the back of the head and neck forms in the first place. According to some experts, the incorrect growth of hair after shaving too closely to the skin may cause folliculitis to develop. In patients prone to AKN, follicles swell and then create a single back of head bump, which eventually evolves to something resembling razor bumps on the back of the head.
Shaving hair that is already short causes irritation to occur and increases an individual’s chances of developing AKN if they are genetically predisposed to this condition. Inflammation of hair follicles while shaving areas like the back of the head or the neck can result in the formation of thick scars and bumps, which can be categorized as papules. AKN first manifests as these bumps on the back of the head requiring treatment immediately in order to resolve. If the condition is not treated, the growths eventually combine into a single, keloidal mass of tissue.
Dr. Umar believes that the condition of AKN is primarily hormone-based. Dr. U’s opinion is based on the fact that many AKN patients have a tendency to develop other DHT-influenced conditions such as acne vulgaris. Acne keloidalis nuchae predominantly affects men compared to women, who have less DHT activity than men.
Dr. U believes that bacteria plays very insignificant role in the etiology of AKN. Although secondary infections can occur, it is a rare phenomenon. According to Dr. Umar, the pustules from acne keloidalis nuchae are typically the result of sterile inflammation, not due to microbes.
Who Might Develop Acne Keloidalis Nuchae?
Researchers show that acne keloidalis nuchae, or “barber’s rash” on the back of the head and neck, typically affects men ages 13-25 of African descent. This is because they are more likely to have tightly-curled, short coarse hair. Other races, including Hispanics and Asians, can also be affected by acne keloidalis nuchae to a lesser degree. AKN is very rare in Caucasians and is extremely rare in women. The ratio of men to women suffering from this skin condition is an estimated 20:1.
Pathoetiology: How Do AKN Lesions Form?
AKN may develop due to the immune system’s failure to discern the body’s own hair from a foreign, infectious agent. As a result of this mistaken identification, the body becomes inflamed, which then causes bumps to develop on the skin. Fibrosis (thick scar tissue) forms while the skin attempts to heal and repair the damage caused.
Fibroblasts (cells that produce collagen) produce thick scar tissue that distort and block the growth of the hair follicles. The hair shaft becomes trapped underneath the skin, which propagates an ongoing cycle of scarring and inflammation. This then causes hypertrophic scar tissue to develop, typically creating bumps on the back of the head that need treatment. Even a single, small back of head bump will grow into many more, which then join together to form large plaques (flat lesion). Oftentimes, they grow to form a larger bump on the back of the head and neck that can assume tumor like or keloidal proportions.
What is the Justification for the Term Razor Bumps on the Back of the Head or Even Barber’s Rash on the Back of the Head?
Does shaving close to the skin affect the onset of AKN? Most patients report an incident of close shaving of the affected areas prior to the condition’s onset. This leads many sources to posit that AKN might be caused by shaving too close to the skin, friction with the skin, and irritation. Environmental variables such as these damage the hair follicle, breaking it and encouraging the tight, curled shaft to grow back into the skin. One study observed that 90% of individuals affected saw their symptoms manifest after they had used an electric-powered razor to shave their head or neck area.
Dr. U observes that most of his patients have reported close shaving prior to the emergence of the initial bumps on the back of the head. Dr. U believes the friction encourages the tightly curled shafts of hair to grow back into the skin. This then causes keloids to form on the back of the head.
Acne Keloidalis Nuchae Treatment Methods: How to Treat AKN
If you’re wondering “How to get rid of a bump on the back of my neck and head” The acne keloidalis nuchae treatment recommended for an AKN patient is tailored to the stage of the patient’s condition. Treatment options for the condition include:
Medications: Drugs such as steroids (topical and intralesional) and antibiotics (topical and oral) are typically used for the relief of uncomfortable symptoms like itchiness, pain, discharge and swelling which are effectively relieved by the use of steroids. Antibiotics are typically useless. The bumps on the back of the head respond to treatment through drugs by shrinking in size, however this remission period is only temporary and not a cure. The patient below is an example of topical steroid that were partially effective for the first five to six months before the lesions returned.
Laser treatments: The use of lasers may be effective for cases in which the inciting factor is hair irritation. It is typically effective in small, scattered bumps on the back of the head. It is not effective in well-established nodules, plaques or masses. There is also the downside of possible hair loss in the treated area.
Ablation: AKN can be ablated or destroyed with the use of CO2 lasers and liquid nitrogen. Ablative agents like cantharidin are used by some treatment centers for acne keloidalis nuchae. These treatments, however, typically result in scarring and are not always effective.
Surgery: Acne keloidalis nuchae treatment via surgical removal is perhaps the most effective and potentially curative treatment if properly performed on suitably selected patients. This approach is suitable for those who’ve just begun to notice symptoms like razor bumps on the back of the head (although laser would likely be attempted first) to those with flat plaques.
The general treatment field had previously lacked objective patient criteria for deciding on which surgical method to use. This often resulted in final cosmetic results are which are often less than satisfactory for most patients. Examples include highly noticeable scarring as well as recurrence of lesions. To solve these problems, Dr.U has developed a system for qualifying individuals for specific surgical and laser interventions, enabling them to benefit from better and more predictable long-term outcomes. He has also innovated upon existing methods to help patients achieve significantly improved cosmetic results which are less conspicuous, helping them to feel more confident in social situations. His work has been published in JAAD (Journal of the American Academy of Dermatology) and PRS(Plastic and Reconstructive Surgery)Global Open.
Dr. Umar’s Customized Approach to AKN Treatment
Dr. U innovates surgical and laser methods for effectively treating AKN. This results in actual cures for the majority of his patients. The techniques Dr. Umar employs for acne keloidalis nuchae removal include:
- excisions with tension sutures assisted second intention healing
- posterior hairline migration
- trichophytic closure
Dr. U has effectively transformed the lives of many patients who suffer from AKN for the better, enabling them to be free of their limiting condition. Additionally he makes acne keloidalis nuchae treatment for adults as cost-effective as possible.
Dr. U is recognized globally as a leader in acne keloidalis nuchae treatment. He is consulted by patients worldwide who complain of “razor bumps on the back of the head.” Dr. U’s esteemed reputation in acne keloidalis nuchae treatment comes from the surgical technique he developed to treat AKN, referred to as the “Batman excision” due to its unique shape. The uniquely shaped excision method enables the complete excision of lesions in qualified AKN patients with an aesthetically pleasing outcome.
Dr. Umar has also expertly managed early forms of the disease with targeted laser treatments.
Unlike conventional treatments that bring only temporary benefits, like medications, steroid injections, and acne keloidalis nuchae creams, the Dr. U’s unique excision technique, and laser therapy treatments typically result in the permanent curing of almost any size lump on the back of the head and neck. An AKN cure is possible for most patients with Dr. U’s expertise.
Dr.U’s Surgical Approach for Treating Acne Keloidalis Nuchae
Dr.U has evolved conventional surgical approaches for the treatment of Acne Keloidalis Nuchae with the aim of helping patients achieve better long-term cosmetic results. Prior to these advancements, no objective criteria existed for qualifying individuals for specific surgical techniques. Dr.U believes that this is the reason why the quality of outcomes varied across patients, and sometimes with rather unpredictable results. To overcome these issues, Dr.U developed systems for selecting patients based on quantifiable factors in order to match AKN sufferers with effective methods for their particular presentation.
Additionally, he has targeted his excision methods for two specific types of Acne Keloidalis Nuchae lesions.
(1) Lesions less than or equal to 2.5cm in vertical width, located in the upper nuchal area
(2) Lesions less than or equal to 3.0 cm in vertical width, located in the lower nuchal area
Dr.U’s Novel Use of Primary Trichophyic Closure For AKN Lesions in the Upper Nuchal Region
Patients with Acne Keloidalis Nuchae lesions located in the upper part of the general nuchal area which are less than or equal to 2.5cm qualify for primary excision and closure techniques, where the edges of the wound can be sutured together during the surgical procedure. Dr.U also incorporates the use of Trichophytic closure, as a new surgical innovation within the context of AKN procedures. This involves cutting the upper (i.e. superior) wound edge at an angle so that it can be more seamlessly superimposed over the bottom (i.e. inferior) wound margin which includes decapitated hair follicles. The end result is a thinner linear scar through which the patient’s own hair grows. Dr. U’s work has been published in JAAD in an article entitled, Innovative Surgical Approaches and Selection Criteria of Large Acne Keloidalis Nuchae Lesions.
Dr.U’s Bat Excision and Use of Tension Sutures for AKN Lesions in the Lower Nuchal Area
Large, coalesced AKN lesions which are less than or equal to 3.0cm in vertical width and located in the lower part of the nuchal area can be effectively removed using Dr.U’s bat-excision technique. A more cosmetically inconspicuous scar can be achieved by rendering it as a straight, horizontal line that is aligned with the posterior hairline. Performing an excision in the shape of a spread-eagle bat (as opposed to an ellipse) is an effective approach for attaining this objective. Also, the use of tension sutures enables the edges of the wound to close in a more controllable and predictable manner. This methodology and the patient selection criteria associated with it has been reported in PRS Global Open within the publication, Innovative Surgical Approaches and Selection Criteria of Large Acne Keloidalis Nuchae Lesions.
Photos: Dr. U Acne Keloidalis Nuchae Surgery Results
For patients experiencing painful, itchy bumps on the back of the head, optimal treatment is surgical removal. Surgical excision has proven to be the most effective and reliable way of actually removing tumors and plaques. The affected area must be excised by reaching and removing the base of the keloidal tissue, as well as the affected follicles. The type of treatment in most cases is influenced by several factors, including the severity of the AKN symptoms.
Following a thorough assessment, Dr. U develops a targeted course of action with techniques such as excision (complete or partial), trichophytic closure, and posterior hairline migration.
Photos: Before and After Acne Keloidalis Nuchae Surgery
When conducting surgical acne keloidalis nuchae removal, Dr. U strategically positions the surgical wound so that it will form a linear scar in line with the posterior hairline.
Acne keloidalis nuchae: before and after. These images highlight an AKN patient who opted for surgical treatment with Dr. U.
Video: Dr. U Acne Keloidalis Nuchae Surgery Results
The next video features a patient in whom Dr. U performed excision with trichophytic closure.
Laser Treatment Results for Bumps on the Back of the Head
If hair shafts cause the initial bumps on the back of the head, laser can be an effective method of acne keloidalis nuchae treatment. Therapeutic approaches using hair-removing ND:YAG lasers are tested by researchers. These laser treatment tests culminated with a study that shows efficacy in treating papular and even plaque stages of the AKN disease.
In one study, 16 patients treated in 5 sessions monthly achieved remission of over 90% in AKN in the papular stage. After 5 treatments, flat plaque disease showed 70% improvement with flattening of the plaques, in addition to a reduction in the size of lump on the back of the head and neck. Dr. U uses the ND:YAG laser for papular AKN removal with positive results. The laser targets the offending hair, removing or weakening it in order to ensure that it can no longer cut into the skin and restart the cycle of hair stab-irritation-tissue fibrous response.
Dr.U’s Patient Selection Criteria and Advanced Application Techniques For Laser AKN Treatment
Dr. U has developed an objective patient selection system for laser treatment in individuals with early-stage Acne Keloidalis Nuchae. In this phase, the lesions manifest as individual papular-nodule bumps. However, Dr.U recommends the use of laser specifically for lesions less than or equal to 2mm in vertical height. Furthermore, since there is a wide variation in the spread of these bumps on the back of the patient’s head, Dr.U has also developed categories of laser application based on the severity of the AKN spread. Prior to this, the general technique used involved the application of laser to individual bumps. The drawback to this approach was a patchy appearance, spots of baldness, surrounded by hair.
By applying the laser to completely remove zones of hair, when the spread is restricted to the nape area, patients would have a slightly raised posterior hairline above the treated region. This would allow individuals to maintain a more uniform and natural looking coverage, while resolving their AKN lesions.
Cases, where the spread is more extensive throughout the scalp, can either be completely or partially epilated, depending on the patient’s choice. Many individuals prefer to have some hair remaining. And this approach would allow for them to have this option.
More information on Dr.U’s selection criteria, treatment zones and overall methodology for the application of laser can be found on his JAAD publication, Selection criteria and techniques for improved cosmesis and predictable outcomes in laser hair removal treatment of acne keloidalis nuchae.
Photos: Before and After Results of Acne Keloidalis Nuchae Treatment With Lasers
Acne Keloidalis Nuchae Before and After ND:YAG Laser Treatment with Dr. U.
Video: Results of Acne Keloidalis Nuchae Laser Treatment by Dr. U
The following video features a patient who received a series of laser treatments by Dr. Umar. This particular approach resulted in permanent removal of AKN, which he thought to be razor bumps on the back of his head.
Frequently Asked Questions: Acne Keloidalis Nuchae
How do I determine if the lump on the back of my head and neck is AKN?
To rule out other skin conditions, it’s important to receive a diagnosis from a doctor specialized in acne keloidalis nuchae. Diagnosis starts with recognition of AKN signs, which are the characteristic bumps on the back of the head, or single large bump on the back of the head and neck. Next, the doctor would take a biopsy to get a histologic diagnostic confirmation of clinical suspicion. A histologic report is the final and definitive diagnostic tool for AKN.
How do I get rid of bump on the back of my neck and head using a home remedy?
When it comes to treating this medical condition, no AKN home remedy is effective. Again, the causes of AKN are very complex. The condition may be due to issues like hormones, genetics, inflammation of the hair follicles. Therefore, individuals experiencing razor bumps on the back of the head and neck should turn to laser, surgical, or medical treatments discussed here.
How to get rid of a large bump on back of my head and neck: is there such a thing as a cure for acne keloidalis nuchae?
Yes. According to Dr. U’s experience, there are two instances of therapeutic cure using current treatments:
- Surgical treatment, if the lesions in an area are amenable to complete removal.
- Laser treatment in early stage disease states. Using the correct laser in combination with prescription acne keloidalis nuchae creams, Dr. U has successfully cured the bump on the back of the head and neck for several AKN patients.
What is the cost of acne keloidalis nuchae removal surgery?
The cost should vary with the kind of lesion and the extent of the surgery needed. To determine the cost of your surgery, seek a complimentary consultation which is available by most doctors who offer the procedure, like Dr. U. Following evaluation, you will be provided with a detailed treatment recommendation and associated costs, which may include other services like sending your AKN lesion to a pathologist. Considering the transforming and freeing experience expressed in videos by Dr. U’s patients, the cost is well worth the expenditure.
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