Continual maintenance strategies are key for addressing three chronic follicular disorders in skin of color.
Acne Keloidalis Nuchae in an African American man. Note the typical location on the posterior scalp and the characteristic clinics features of fibrotic follicular papules, some of which are inflamed.
Continual maintenance strategies are key for addressing three chronic follicular disorders that affect primarily men of African ancestry: pseudofolliculitis barbae, acne keloidalis nuchae and dissecting cellulitis, according to dermatologist Andrew F. Alexis, M.D., M.P.H., who directs the Skin of Color Center in New York City.
Dr. Alexis, who is also dermatology chair at Mount Sinai St. Lukes and Mount Sinai Roosevelt, New York, N.Y., presented on the topic of follicular disorders in men of color at the 2015 Skin of Color Seminar in New York City. Dr. Alexis says that pseudofolliculitis barbae is the most prevalent of the three conditions. Depending on the literature cited, pseudofolliculitis barbae affects between 45% and 83% of men of African ancestry.
“So, it’s extremely common,” Dr. Alexis says. “It’s exacerbated by shaving. The sharp tip of the hair shaft that’s caused by shaving, coupled with the curved structure of the hair shaft, contributes to re-entry of the hair shaft into the skin, causing a foreign body inflammatory reaction. This, in turn, leads to papules and pustules and postinflammatory hyperpigmentation.”
Treating and managing pseudofolliculitis barbae requires medical and lifestyle strategies. Growing a beard can cure the condition, according to the dermatologist.
“There are various approaches to treating these patients, including some adjustments to shaving technique or discontinuation of shaving, altogether. Growing a beard is actually curative in most cases and results in resolution within six to eight weeks,” says Dr. Alexis.
For patients who want to continue to shave, there are shaving techniques that are less likely to aggravate the condition. Among the tips to give patients: Shave with the grain and don’t pull the skin taut during shaving.
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Dr. Alexis recommends patients use topical anti-inflammatories right after shaving, such as a low potency corticosteroid, topical dapsone 5% (which is off-label) or clindamycin gel. Dr. Alexis says he has found, anecdotally, that the antiinflammatory properties of these topicals can reduce the development of bumps associated with pseudofolliculitis barbae.
“There is a study using benzoyl peroxide and clindamycin in a fixed combination (5% and 1%, respectively), which did show significant reduction in papules and pustules compared to vehicle,” he says.1
Laser hair removal is a great option for those patients who don’t respond to treatment.
“That’s curative,” Dr. Alexis says. “But it requires multiple sessions and is paid out-of-pocket. There are risks involved with doing laser hair removal on darker skin types. But when using the appropriate laser, such as a long-pulse 1064 Nd: YAG, which would be considered the safest in darker skin types, it’s a viable option.”
Acne keloidalis nuchae, also known as folliculitis keloidalis nuchae
is another follicular disorder that occurs disproportionally in men of African ancestry, according to a study on which Dr. Alexis is among the authors.
The potentially disfiguring chronic disorder usually affects the nape of the neck in African American men. Acne keloidalis is a follicular inflammation, which results in a keloidal reaction and can cause irreversible alopecia.
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In Dr. Alexis’s experience, the best treatment strategy is to use topical antimicrobial agents and systemic antibiotics as a first-line to treat active folliculitis and corticosteroids to reduce fibrosis.
Surgical excision is an option for these patients. And recent studies suggest phototherapy or laser epilation of the hair might also help these patients.
In another study, researchers found laser hair depilation with five sessions of the long pulsed Nd-YAG to treat acne keloidalis nuchae significantly decreased the inflammatory infiltrate and markedly decreased sclerosis. The researchers concluded that laser hair depilation can improve the disorder, and “starting treatment as early as possible achieves the best results and can stop the disease process if followed by maintenance sessions.” 3
Dissecting cellulitis of the scalp is rare. Only 72 patients with the condition have been published in the literature, according to a recent review.4
When it is diagnosed, it is most commonly seen in African American men from ages 20 to 40.5
Characterized by painful nodules with purulent discharge and hair loss, dissecting cellulitis can be a frustrating condition to medically manage, according to Dr. Alexis, who indicates that the gold standard treatment for the condition is oral isotretinoin 0.5–1 mg/kg/day. According to Dr. Alexis, “several treatments have been tried, among them, only systemic retinoids permitted to achieve complete remission.”4
Daily oral quinolone, topical and oral antibiotics, topical isotretinoin, oral zinc and oral dapsone are other treatment options, he says. And, while intralesional corticosteroids can help temporize the nodules, the treatment option does not result in long-term remission.
TNF-blockers hold promise in the treatment of dissecting cellulitis of the scalp. Adalimumab and infliximab have been studied with some success, according to Dr. Alexis. Researchers have reported success with the use of surgical excision of scalp lesions for severe or recalcitrant dissecting cellulitis. Dr. Alexis says that dermatologists can perform incision and drainage of nodules to provide patients with immediate relief.
“[Acne keloidalis nuchae and dissecting cellulitis of the scalp] are therapeutically challenging, chronic follicular disorders that disproportionately affect men of African ancestry. Successful treatment outcomes can be achieved with a combination of medical and procedural therapies, as well as behavioral modification. However, given the relapsing nature of these disorders, long term follow up is necessary,” he said.
Women of all skin types can get folliculitis, particularly in the bikini and axillae areas, where they shave. It’s often associated with hyperpigmentation, which can be a great concern to patients of color, according to Dr. Alexis.
“I use topical retinoids in the evening and a topical benzoyl peroxide/clindamycin preparation or 5% dapsone gel (off label) in the daytime, in combination with the retinoid,” he said. “For those with severe hyperpigmentation associated with folliculitis barbae, I would use a triple combination of formulas that contain tretinoin, fluocinolone and hydroquinone 4%, nightly.”
Disclosure: Dr. Alexis is a consultant for Allergan, Amgen, Galderma, Roche, and Valeant and an investigator for Allergan and Novartis.
2. Alexis A, Heath CR, Halder RM. Folliculitis keloidalis nuchae and pseudofolliculitis barbae: are prevention and effective treatment within reach? Dermatol Clin. 2014 Apr;32(2):183-91. http://www.ncbi.nlm.nih.gov/pubmed/24680005.]
3. Esmat SM, Abdel Hay RM, Abu Zeid OM, Hosni HN. The efficacy of laser-assisted hair removal in the treatment of acne keloidalis nuchae; a pilot study. Eur J Dermatol. 2012 Sep-Oct;22(5):645-50.
4. Badaoui A, Reygagne P, Cavelier-Balloy B, Pinquier L, Deschamps L, Crickx B, Descamps V. Dissecting cellulitis of the scalp: a retrospective study of 51 patients and review of literature. Br J Dermatol. 2015 Jul 2. http://www.ncbi.nlm.nih.gov/pubmed/26134994
5. Williams CN, Cohen M, Ronan SG, Lewandowski CA. Dissecting cellulitis of the scalp. Plast. Reconstr. Surg. 77(3),378–382 (1986)