Acne Keloidalis Nuchae

It starts at the very back of the neck, right along the hairline, with a few small firm bumps. What separates it from ordinary razor bumps is that the bumps do not go away — they harden.

What it looks and feels like

Where it shows up

• The back of the neck and the lower hairline, almost always. This is where it starts.
• The back of the scalp above the hairline, as it extends upwards.
• The occipital scalp — the crown at the back — in advanced cases.
• It does not appear on the face, chest or back. If bumps are there too, something else is going on.

How it looks on different skin tones

This condition is almost entirely seen on brown and Black skin, so the descriptions written for lighter skin are of limited use. The bumps usually look skin-coloured, dark brown or violet rather than red, and the inflammation can be hard to see against the surrounding skin. That means the first thing many people notice is texture, not colour — running a hand over the nape and feeling bumps that were not there before. Because the scar tissue is also raised and often darker, the visible damage tends to be recognised at a stage when it is already permanent.

A few other things cause bumps at the hairline. See Lookalikes near the bottom of this page.

The cause is not fully settled, but the picture is reasonably clear. Tightly curled hair at the nape grows out of a curved follicle and is prone to re-entering the skin, exactly as it does in razor bumps. When it does, the body reacts to the buried hair as a foreign object. At the back of the neck that inflammation sits deeper in the follicle and it persists, and persistent inflammation around a follicle produces scar tissue.

Several things feed into it. Close clipping or shaving of the nape, particularly with clippers held flat against the skin, cuts hairs to a sharp point below the surface. Constant friction from shirt collars, helmets and sports gear rubs the same strip of skin. Bacteria in the follicles add to the inflammation once it is running. Some evidence points to a naturally weaker follicle wall in this area in susceptible people, and there may be a hormonal element given how strongly it favours men.

What it is not: it is not acne, and the name is a historical mistake that has stuck. It is also not caused by dirt, sweat or infrequent washing. Saying this plainly matters, because a lot of what is written about it implies otherwise.

Very little of this is manageable at home, and treating it alone costs you permanent scarring. What is here is worth adding alongside prescription treatment, not instead of it.

Go early. This is the point of the page.

• You have small firm bumps at the back of your hairline that have lasted more than a few weeks.
• Bumps are becoming hard, raised or joined together.
• There are bald patches within the affected area.
• The area is sore, itching, discharging or crusted.
• Bumps keep coming back after every haircut.

What the visit gets you: prescription treatment that works on active bumps, steroid injections that flatten early raised lumps, antibiotics where infection is part of it, a plan for the hair removal that stops it recurring, and — for scar tissue that has already formed — a realistic discussion of surgical removal. Going in at the small-bump stage is the difference between a condition that is controlled and one that leaves a permanent band of scar across your neck.

This is where treatment for acne keloidalis nuchae really starts. What you are given depends on whether the bumps are still soft and inflamed or have already hardened.

Done in a clinic. This band covers both flattening or removing scar tissue that has already formed, and removing the hair that keeps the process going.

The complications are the condition. Left alone, this is one of the few common follicular problems that ends in permanent damage.

• Permanent scarring alopecia. Once a follicle is destroyed by scar tissue, the hair does not come back. This is not reversible by any treatment.
• Keloid-like plates. Individual bumps merge into thick raised bands across the nape. These can be uncomfortable against collars and are only removed surgically.
• Repeated infection. Pus, crusting and abscesses in the affected area, sometimes requiring drainage and oral antibiotics.
• Sinus tracts. In advanced cases, tunnels form under the skin that discharge and are difficult to treat.
• Ongoing pain and itch. Not trivial. A thickened, inflamed strip at the back of the neck rubbing on clothing is a daily nuisance.
• The visible and social cost. It sits in a spot other people see and you cannot. That combination, on a condition that is often wrongly assumed to be about hygiene, is a genuine burden and a fair reason to get it treated.

Several things cause bumps at the back of the neck.

• Razor bumps (pseudofolliculitis barbae) — the same mechanism, but the bumps stay soft, come and go with shaving, and do not harden into scar tissue. Acne keloidalis nuchae is specifically at the nape and specifically scars. The two often occur in the same person.
• Keloids — raised scars that grow beyond the boundary of the original injury, usually after a cut, piercing or surgery. Acne keloidalis nuchae looks keloid-like but starts from inflamed follicles, and true keloids are not confined to the hairline.
• Bacterial folliculitis — crops of tender pustules that clear completely with an antibiotic and leave no lump behind. If the bumps resolve without a trace, it was not this.
• Folliculitis decalvans — another scarring scalp condition, but usually on the crown, with tufts of several hairs emerging from one opening and more pronounced pustules and crusting.
• Dissecting cellulitis — boggy, fluctuant lumps and tunnels across the scalp rather than firm bumps at the hairline. It often occurs alongside acne keloidalis nuchae.
• Acne — blackheads and whiteheads, on the face, chest and back as well. Acne keloidalis nuchae has no blackheads and stays at the nape.