What is the role of surgery in the treatment of acne keloidalis nuchae (AKN)?

Updated: Nov 13, 2020
  • Author: Elizabeth K Satter, MD, MPH; Chief Editor: William D James, MD  more...
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Answer

Laser ablation using various lasers (eg, carbon dioxide, 1064-nm Nd:YAG, 810-nm diode) should be considered for lesions refractory to other treatments. [26] One case series showed that 4 monthly laser hair epilation sessions using the diode laser (810 nm) in addition to a topical retinoid and steroid resulted in long-lasting improvement in the appearance and prevention of lesions. Laser hair epilation allows for coagulation necrosis of both viable hair follicles and fragmented hair shafts in the deep dermis. [27, 28, 29, 30]

Stable fibrotic lesions may be anesthetized with lidocaine and removed with punch biopsy or excision. The punch should extend deep into the subcutaneous tissue so that the entire hair follicle is excised. Superficial biopsies tend to have a much higher incidence of recurrence. After excision is performed, the wound edges can be injected with 10-40 mg/mL of triamcinolone acetonide to reduce inflammation. Silk sutures may be used to re-approximate the skin as they cause less of an inflammatory response than nylon sutures. Instruct patients to clean the postoperative area 3 times a day with a mild cleanser, followed by application of a topical antibiotic ointment. The sutures should be removed in 7-10 days, and the patient should then begin a twice-daily topical retinoic acid/corticosteroid regimen for 4-6 weeks.

The preferred method of excision for larger linear lesions (1 cm or less in diameter) is a horizontal ellipse with primary closure; however, excision by carbon dioxide laser and electrosurgery followed by secondary-intention healing are also viable options, especially for lesions that cannot be easily closed primarily. [11, 31]  The excision should extend below the hair follicles, and the area should be reapproximated with 4-0 silk sutures.

Always remember that when closing the area, ensure the patient’s neck is not in a flexed position; otherwise, the patient will spend a week or longer having to look upward.

An important caveat with surgical excision is that primary closure often results in recurrences and/or hypertrophic scarring, and data show that allowing lesions to heal by secondary intention results in fewer recurrences. Wound healing is typically achieved within 6-10 weeks, and, in general, the surgical site contracts to an area smaller and flatter than the original site. [32, 33]

Postoperative care is basically the same as that for punch grafts. Pain medication may be necessary for the first 48 hours.

Have patients return in 24-36 hours (preferably with the person responsible for changing dressings) for removal of the initial dressing. Soak the area with sodium chloride solution to facilitate the removal of the dressing and to clean the postoperative site.

Instruct patients to start cleaning the site twice a day (following the regimen above) once the dressing is removed. Instruct patients to return for follow-up in 1 week, or, sooner, if any complications occur.

Instruct patients to return for follow-up care for possible initiation of intralesional steroid injections or to begin topical steroid/retinoic acid therapy once the area has healed, usually in 2-3 months. Do not begin intralesional steroids prior to complete would healing because this can result in wound dehiscence.

A follicular papule or pustule occasionally develops along the border of the linear scar. Treat all inflammatory lesions with topical clindamycin until the infection subsides. The residual papule can then be treated with topical or intralesional steroids or excised via a punch biopsy.

Excision followed by grafting is typically not cosmetically acceptable because it results in a large, depressed, non–hair-bearing area.


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