II. Pathophysiology

  1. Idiopathic, chronic inflammatory condition leading to Hair Follicle scarring
  2. May be secondary to localized foreign body reaction to hair (similar to Pseudofolliculitis Barbae)
  3. Increased androgen levels play a part in pathogenesis (hence male predisposition)

III. Epidemiology

  1. Most common in black men
    1. Also occurs in hispanic, asian and white men
    2. Women are much less commonly affected (male to female 20:1)
  2. Onset after Puberty and typically not after age 50 years

IV. Symptoms

  1. Variable pain and Pruritus

V. Signs

  1. Papules and Pustules on occiput and neck (each 2-4 mm)
  2. Papules and coalesce into Keloid-like mass in band-shape on the occipital scalp and posterior neck
  3. Cicatricial Alopecia occurs in involved neck and occiput region

VI. Associated Conditions

VII. Complications

  1. Subcutaneous abscess with draining sinus
  2. Scarring Alopecia in involved area

VIII. Management

  1. General Measures
    1. Avoid tight fitting shirts, helmets, hats or other clothing that rubs the occipital and nuchal area
    2. Avoid shaving or tightly clipping hairs in the occipital and nuchal region
  2. Initial medical management
    1. Topical Corticosteroids
      1. Start with topical triamcinolone 0.1% cream for 3 to 4 weeks in mild cases (Papules <3 mm)
      2. High protency Topical Corticosteroids (e.g. Clobetasol, Betamethasone) may be needed in more significant cases
    2. Intralesional triamcinolone (5 to 40 mg/ml)
      1. Consider in moderate cases (Papules >3 mm)
    3. Topical Retinoids (e.g. Retin A)
      1. Consider as adjunct to Corticosteroids
    4. Topical Antibiotics (e.g. Clindamycin 1% solution)
      1. Consider if Pustules are present
  3. Additional medical management
    1. Oral antibiotics (e.g. Doxycycline)
    2. Imiquimod (Aldara)
    3. Oral Isotretinoin (Accutane)
    4. Cryotherapy
  4. Refractory cases
    1. Laser Therapy (most effective)
      1. Woo (2018) J Cutan Med Surg 22(2): 236-8 [PubMed]
    2. Phototherapy (UVB)
      1. Okoye (2014) Br J Dermatol 171(5): 1156-63 [PubMed]
    3. Surgical excision

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