Hey what’s going on guys? Welcome to another video. Today I want to do a case presentation of a patient that I thought was very interesting. And this patient was unfortunately misdiagnosed by a couple of physicians that were seeing him prior and the only reason I know about this condition is because I have seen it actually two or three times before him as well. First time I saw it, I had no idea what I was dealing with, so I grabbed somebody else to take a second look/second opinion; never seen that condition either. So, I thought this would be a pretty interesting case, and if you were to run into somebody with this condition, you would know what to do.  So let’s get started, alright?

Soooo… this condition is called acne keloidalis nuchae and the patient that presented was a twenty-year old male. He came in because he was having hair loss, papules pustules over the occipital part of his scalp and neck. Now he is an athlete, he sweats a lot, so the misdiagnosis was tinea capitus, and they thought this was a fungal infection. They started him on Terbinafine, they gave him anti-fungal shampoo, and he noticed no improvement.  So he went somewhere else. Where the same physician also said this is tinea capitus and again treated him with different types of anti-fungal. Placed him on Ketoconazole. Again, no improvement so he is obviously doctor shopping or what not, so he ended up in our clinic. He is the third patient I have seen with this condition. So I thought I would share this with you guys now.

Now these papules and pustules, they actually do have fluid that actually comes out. So it does look like a bacterial infection.  It doesn’t present with the isolated alopecia that you would see with tinea capitus, although he does have hair loss; which is probably why they thought this was tinea.

But basically this is not my patient, this is a picture that I pulled off the internet, however he looks very similar to this. So if you can see here he is losing his hair, however there are papules here. And sometimes these papules are pustular so there’s actually discharge that comes out. You don’t see that in tinea. You don’t see papules and you don’t see discharge in tinea. This is essentially what it looked like and it’s always going to be isolated to this posterior neck region here and the occipital part of the scalp. You’ll never see it on top up here; you’ll never see it in the temporal areas, so always look behind.

Alright so what causes this? Now, who knows right? They don’t really know the exact ideology; it’s probably due to close shaving, which causes ingrown hairs, it probably causes secondary bacterial infection, it can probably be due to constant irritation. So patients that are athletic, they wear helmets, that constant rubbing of the helmet, causes this acne (I guess if you will) to form and it’s not really acne. So you’re not going to see patients that actually have acne Vulgaris that have this condition, this is more of a folliculitis. And why the exact reason for a folliculitis isn’t really known. but they do know that close shaving will exacerbate, they do know that constant irritation will exacerbate.  There’s some discharge, and when cultures are taken, a lot of times there is also secondary bacterial infection; but who knows if the bacterial infection is secondary because of this chronic irritation? Or if in fact is the cause?

So how did I treat this guy? There’s no real good management, and I told this guy upfront “this is difficult to treat” as I stated earlier in other videos, podcasts, and whatnot. When there are different possible ideology there’s no good treatment. So basically we’re throwing something that the wall and we’re seeing what sticks. So what I did for this guy was, you need to avoid short haircuts, because he did, he was actually very close shaven, probably did a one all the way around.  I told him that if he keeps playing these sports, it’s probably going to exacerbate the problem and it’s probably going to be more difficult to treat. So I gave him that option. It’s up to him if he does or does not; I also gave him tar shampoo. It’s been shown that it might possibly help, doesn’t hurt, and I gave him Clobetasol. So they actually found that these high potency steroids might decrease the symptoms, because it’s probably not a bacterial infection, it’s definitely not tinea.  He had discharge, but I didn’t bother with the culture, just gave him Chlindamycin. And the reason we didn’t do the culture was because it was a non-insured patient who couldn’t afford to do a culture on top of the treatment here. So I started him on tar shampoo, Clobetasol, Clindamycin and I said let’s see you back in a month. So he’s going to have a follow up in a month, I think the last time I saw him, it’s probably been about two weeks now, so we’ll see how he does in the next month.

Now the other options that are available if this is not working or if you’re not seeing any type of improvement is to do steroid injections. You can give Triamcinolone and actually inject it into the papules and over time that will start to decrease. He should let his hair grow out, he should avoid sports as we said earlier and if the Triamcinolone doesn’t work the next option would probably be some surgical resection. And at that point he obviously needs to see a dermatologist who is experienced with this type of condition. But at least I can get the ball rolling for this guy and try the shampoo, the Clobetasol, the Clindamycin. Steroids may or may not work as far as oral steroids go, it is an option for refractory cases.  So, we’ll see how he does next month, but I thought this would be a good case just for you guys to be aware of.  This is the presentation..you can see the papules, pustules, and you’re going to see alopecia, and you’re going to see discharge. Always posterior neck, occipital region of the head. So don’t confuse that with tinea capitus.

Alright guys, quick presentation today.  Just wanted let you guys know about this patient that I saw that you guys can benefit from, take this to your clinical practice and don’t misdiagnose somebody with tinea. Find my website over at physicianassistantboards.com find me on Facebook facebook.com/paboards1 find me at twitter @PA_Boards alright guys. Thank you so much for joining me and I will see you guys on the next video.