Acne keloidalis in caucasian patients on cyclosporin following organ transplantation

Sir, Acne keloidalis or folliculitis keloidalis is a chronic inflammatory, scarring dermatosis due to folliculitis and perifolliculitis of the hairs of the occipital scalp and nape of the neck, which is seen most commonly in young black males1 and is uncommon in caucasians. We report three caucasian males, treated with cyclosporin following organ transplantation, with acne keloidalis of the occipital scalp and nuchal neck. The first patient was a 46‐year‐old caucasian man with hypertensive chronic renal failure which necessitated cadaveric renal transplantation. He was treated with cyclosporin 500 mg daily, azathioprine 100 mg daily, prednisolone 20 mg daily, metoprolol, aspirin and nifedipine. Three years following transplantation, he was referred with an 18‐month history of pruritic papules affecting the posterior scalp. There was no preceding history of skin problems. On examination, he had multiple pink papules and nodules affecting the back of the neck and lower occipital scalp (Fig. 1). Skin biopsy showed a large intradermal and perifollicular abscess; there was neutrophilic inflammation of the hair shaft and perifollicular area with evidence of scar tissue formation. Skin swabs grew Staphylococcus aureus and mycological culture was negative. Treatment with flucloxacillin 500 mg twice daily for a month did not help him. His immunosuppressive treatment is under review by the nephrologists. Acne keloidalis affecting the nape of the neck and occipital scalp. The second patient, a 43‐year‐old caucasian man, had nephrotic syndrome and membranous glomerulonephritis which required cadaveric renal transplantation. He was treated with cyclosporin 400 mg daily, labetalol, nifedipine and frusemide and soon developed discrete papules on the back of the neck. Four years later, he was referred to a dermatologist with a diagnosis of molluscum contagiosum.2 Skin biopsy was suggestive of acne keloidalis and treatment was started with topical clindamycin 1% lotion followed by intralesional triamcinolone acetonide 15 mg. Response to treatment was not followed up as his general health later deteriorated and he died. The third patient was a 30‐year‐old caucasian man referred with an itchy, papular eruption on the nape of his neck and posterior scalp. He had undergone heart transplantation 3 years earlier and was treated with cyclosporin 425 mg daily, prednisolone 2·5 mg daily, azathioprine 50 mg daily, atorvastatin and amiloride. The eruption on the nape of his neck developed a few weeks after transplantation, and increased in size despite treatment with topical corticosteroids and systemic antibiotics. Examination showed multiple discrete flesh‐coloured follicular papules and one large area of hypertrophic tissue covered the whole of the posterior scalp. Skin biopsy showed infiltration with leucocytes, plasma cells, lymphocytes and histiocytes infiltrating around hair follicles and hair shafts with dermal fibrosis; the hypertrophic area showed no evidence of viral wart infection. Treatment with flucloxacillin for S. aureus infection and a trial of CO2 laser evaporation was unsuccessful. He was then referred to the department of plastic surgery to have the hypertrophic element excised. Skin diseases are a significant cause of morbidity in chronically immunosuppressed patients,3,4 who are prone to folliculitis and bacterial skin infections. Acne keloidalis most commonly occurs in young, black males and in one series of 38 affected males, S. aureus infection was the most common bacteria cultured from the lesions.5 It is of note that S. aureus was grown from 2/3 of our patients. The aetiology of acne keloidalis is likely to be multifactorial; the increased curvature of scalp hairs can be causative in pseudofolliculitis and keloid scarring.6 Others state that acne keloidalis may be a variant of lichen simplex chronicus.7 Cyclosporin has been implicated in a hyperplastic response to pseudofolliculitis barbae in a renal transplant recipient and this reaction was thought analagous to the relationship between gingivial hyperplasia and gingivitis that can occur due to cyclosporin.8 Acne keloidalis‐like lesions have also been described affecting the scalp in an epileptic patient on diphenylhydantoin and carbamazepine – the lesions only resolving on cessation of this drug combination.9 Both cyclosporin and diphenylhydantoin can cause hypertrichosis and this might suggest that increased hair growth was relevant to the aetiology of the acne keloidalis in these cases. Treatment of acne keloidalis is difficult but should firstly involve clearance of any bacterial infection with topical antiseptics and oral antibiotics; a number of other therapeutic options are available including topical or intralesional steroids and cryosurgery.10 Deep surgical excision of acne keloidalis with second intention healing has been reported11 and carbon dioxide laser excision treatment is an alternative therapeutic option.12 In summary, we have described three organ transplant patients showing similar clinical and histopathological features of acne keloidalis, whilst on cyclosporin. The aetiology in these cases is likely to be multifactorial, with bacterial infection, immunosuppression, cyclosporin‐induced hypertrichosis and pseudofolliculitis affecting the nape of the neck being the main factors. In many cases, acne keloidalis proves difficult to treat but particularly in organ‐transplant patients on cyclosporin, as this treatment cannot necessarily be altered.