Annoying neck nodules in an adolescent boy

February 18, 2015

Clinical Vignette

A healthy adolescent boy asks you to cure an itchy rash on the nape of his neck, which started over a year ago when he switched barbers. (fig. 1).

Diagnosis and Clinical Presentation

This young man has acne keloidalis nuchae resulting from pseudofolliculitis Pseudofolliculitis barbae (PFB) is chronic inflammatory process of the hair follicle that develops in response to shaving. Multiple factors play into the etiology, including the shape of the hair follicle, the type of hair, the direction of growth, and the modality of hair removal (1, 3-5). When cut, sharpened hair shafts coil as they grow out leading to either extrafollicular re-penetration or transfollicular transection of the skin (1, 3, 5). This incites a foreign body inflammatory response that is clinically characterized by painful or pruritic papules, pustules and nodules (1, 3, 5). Recurrences induced by repeated shaving may lead to hyperpigmentation with hypertrophic or even keloid-like scarring in individuals prone to keloid formation. It is most common in the anterior neck of males. However, it can also occur in the groin, axilla or the nape of the neck (1, 3). The curved contours of these sites predispose them to hair shaft reentry.

Epidemiology and pathogenesis

Populations with tightly curled hair, such as African Americans and Hispanics, are predisposed to developing pseudofolliculitis barbae (PFB) (1-3). The nature of African American hair enables easy skin penetration due to its variability in diameter, coiled pattern of growth and elliptical cross section(4). Some statistics state that between 45% and 83% of young adult African American males suffer from some form of PFB (1, 3, 5). It is particularly a problem among military personnel, as their profession requires a clean-shaven appearance (3). Although less frequent, females may also develop PFB, especially in the groin or in cases of hirsutism.

Differential Diagnosis

PFB is a clinical diagnosis that is frequently confused with acne vulgaris, particularly in the nuchal region and when keloidal scarring is present. In patients with a predisposition to keloid formation, pseudofolliculitis and acne vulgaris may trigger hypertophic scars and keloids. As a consequence early diagnosis and treatment is critical to prevent the development of permanent scarring and associated pruritus, pain, and disfigurement.

Treatment

Treatment approaches for acne vulgaris, bacterial folliculitis, and pseudofolliculitis overlap and include topical and oral antibiotics, topical benzoyl peroxide, and topical retinoids. However, these therapies do not address the primary trigger of pseudofolliculitis: shaving in PFB prone individuals. If this issue is not addressed at an early stage, irreversible scarring may occur. First, shaving in the direction of hair growth using single bladed razors and clippers should be recommended. This approach decreases the risk of an excessively close shave and resultant ingrown hair (3, 5). However, in many patients complete cessation of shaving is required, which usually results in resolution of inflammatory PFB lesions within 1 month (1, 3). When employers require a clean-shaven professional appearance a trial of chemical depilatory agents with barium sulfide or calcium thyoglycolate may be useful as long as they do not induce an irritant contact dermatitis that may also trigger PFB(3, 5). Furthermore, if shaving cannot be avoided it should be preceded by washing with an antiseptic agent, hydration with a hot, moist towel followed by application of lubricating agents (2). Topical corticosteroids are also helpful in reducing active inflammation. Infrared laser therapy is the most definitive option by destroying hair follicles resulting in permanent hair reduction(2, 3, 5, 6). Surgical excision and intralesional corticosteroids are reserved for the treatment of persistent symptomatic hypertrophic scars and keloids (2).

Our Patient

PFB developed when his new barber began shaving the back of his neck with a straight razor. Our patient asked the new barber to stop shaving the back of his scalp, and we started him on oral minocycline 100 mg twice daily with rapid clearing of inflammatory lesions. The persistent itchy and painful keloidal nodules flattened with high potency topical steroids and intralesional steroids for some of the larger and more resistant nodules.

Conclusion

Pseudofolliculitis barbe is a non infectious inflammatory process involving hair follicles that can lead to the development of keloid formation in genetically prone individuals. Avoidance of shaving and selective use of topical and oral antibiotics and topical and intralesional steroids can result in dramatic improvement of symptoms.

References

  1. 1. Perry PK, Cook-Bolden FE, Rahman Z, Jones E, Taylor SC. Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends. J Am Acad Dermatol. 2002;46(2 Suppl Understanding):S113-9. Epub 2002/01/25. 2. Quarles FN, Brody H, Johnson BA, Badreshia S, Vause SE, Brauner G, et al. Pseudofolliculitis barbae. Dermatol Ther. 2007;20(3):133-6. Epub 2007/09/07. 3. Garcia-Zuazaga J. Pseudofolliculitis barbae: review and update on new treatment modalities. Mil Med. 2003;168(7):561-4. Epub 2003/08/07. 4. Rodney IJ, Onwudiwe OC, Callender VD, Halder RM. Hair and scalp disorders in ethnic populations. J Drugs Dermatol. 2013;12(4):420-7. Epub 2013/05/09. 5. Bridgeman-Shah S. The medical and surgical therapy of pseudofolliculitis barbae. Dermatol Ther. 2004;17(2):158-63. Epub 2004/04/29. 6. Schulze R, Meehan KJ, Lopez A, Sweeney K, Winstanley D, Apruzzese W, et al. Low-fluence 1,064-nm laser hair reduction for pseudofolliculitis barbae in skin types IV, V, and VI. Dermatol Surg. 2009;35(1):98-107. Epub 2008/12/17.

Pattern

Morphology

Pigmentation

Body Site