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 Table of Contents  
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 17-21

Folliculitis keloidalis in an urban market in Lagos, Nigeria: A community survey

1 Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria

Date of Submission04-Nov-2021
Date of Acceptance16-Jan-2022
Date of Web Publication07-Mar-2022

Correspondence Address:
Dr. Olusola Olabisi Ayanlowo
Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcls.jcls_49_21

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Background: Folliculitis keloidalis (FK) also known as acne keloidalis nuchae is a follicular scalp disease found predominantly in males of African origin. Studies suggested that FK is associated with hair care practices and shaving. This study aimed to determine the prevalence of FK in a community in Lagos. Methods: This was a community-based, cross-sectional study at the Sandgrouse market in Lagos Island, Nigeria. Self-administered questionnaires were used to obtain demographic and clinical information. Diagnosis of FK was clinical and included follicular and keloidal papules, pustules, nodules, and tumors at the nape, sometimes spreading to other parts of the scalp, with intense itching. Results: A total of 100 males and 207 women were enlisted in the study and clinically evaluated for features of FK. None of the female participants presented with history and clinical features of FK. Seventy-five percent were between the age of 30 and 60 years. Fifteen male participants had a prior history of FK on the scalp and eight had previous treatment. Examination revealed the presence of FK in four respondents (4%): 3 had only on the scalp and one had on both the scalp and the beard area; and none had keloidal lesions. Conclusion: All respondents with FK presented at the early stage with keratotic/follicular papules. We posit that self-treatment with antibiotics and triple action creams (consisting of potent steroids, antifungal, and antibiotic) sold in the market and over the counter is responsible for the early and mild presentation.

Keywords: African males, follicular papules, folliculitis keloidalis, scalp

How to cite this article:
Ayanlowo OO, Anaba EL, Akinkugbe AO, Otrofanowei E, Cole-Adeife O, Karami M. Folliculitis keloidalis in an urban market in Lagos, Nigeria: A community survey. J Clin Sci 2022;19:17-21

How to cite this URL:
Ayanlowo OO, Anaba EL, Akinkugbe AO, Otrofanowei E, Cole-Adeife O, Karami M. Folliculitis keloidalis in an urban market in Lagos, Nigeria: A community survey. J Clin Sci [serial online] 2022 [cited 2022 May 28];19:17-21. Available from: https://www.jcsjournal.org/text.asp?2022/19/1/17/339150

  Introduction Top

Folliculitis keloidalis (FK) also known as acne keloidalis nuchae and keloidalis nuchae is a follicular scalp disease, found predominantly in males of African origin, although has been reported rarely in females and in other races.[1],[2],[3],[4] Hospital-based studies report frequencies of between 0.7% and 9.4%.[5],[6],[7],[8],[9],[10] Community-based studies are few: Khumalo reported 3.5% in South Africa, while Ogunbiyi reported 2.7% in Nigeria.[11] It is most common between the 3rd and 5th decades of life and accounted for more than 80% of patients with scalp disorders in a hospital-based survey.[6] Studies suggest that FK is associated with haircare practices in African males.

Etiology is not known, however, work done by Knable among athletes in the United States found only players of African descent affected and no Caucasian affected suggesting a racial and genetic predisposition.[2] Histology demonstrated acute and chronic follicular inflammation, granulomatous inflammation, extensive fibrosis, and scarring.[1],[4] Studies across Africa suggest that FK is associated with hair care practices and shaving in African males.[5],[8],[10],[11],[12] Khumalo reported FK was precipitated by injuries sustained (crusts, papules, and bleeding) with cutting the hair close to the scalp.[11],[13] FK is associated with scalp and skin disorders such as chronic scalp folliculitis, folliculitis barbae, cicatricial alopecia, folliculitis decalvans, and hidradenitis suppurativa, especially in people younger than 20 years.[9],[13],[14],[15] It has also been associated with metabolic syndrome (hypertension, diabetes mellitus, and dyslipidemia), and increased fasting blood testosterone.[9],[14],[16],[17]

Clinical features vary from itching, bleeding, papules, pustules, nodular scars to huge tumors on the nape and occipital region, depending on the duration of affectation. Keloidal lesions are associated with an onset greater than 5 years.[9] Several studies have described the hospital frequency of FK; however, these places are referral centers and do not give an accurate picture of the prevalence, clinical characteristics, and magnitude of this condition. This study, therefore, set out to determine the prevalence of FK among traders at an urban market in Lagos.

  Methods Top

This was a cross-sectional study carried out in February 2020 as part of a community survey on scalp and hair disorders at an urban market in Lagos, Nigeria. Lagos is the former capital of Nigeria and the economic hub of the country. It is the most populous city in West Africa with a multiethnic population of about 25 million.[18] Permission was sought from the head of the market and ethical approval was obtained from the health research and ethics committee of Lagos State University Teaching Hospital (LREC/06/10/1297). All participants were traders at the Sandgrouse market in Lagos Island, an urban community of Lagos. A purposive/convenient sampling was employed in recruiting all the traders in the market into the study although a sample size of 450 had been calculated using the sample size formular for a disease with <10,000/population; n = z2 pq/d2. All consenting individuals were enlisted. The study was truncated at the wake of the pandemic and the subsequent lockdown.

The traders gave informed verbal and written consent for the study after the purpose was explained to them. The study was in two parts. The first involved a self-administered questionnaire to obtain demographic details, clinical history, family history, previous history, and hair care practices. The second part involved a physical examination by the dermatologists (the authors). A diagnosis of FK was made in those with follicular and keloidal papules, pustules, nodules, and tumors at the nape and sometimes spreading to other parts of the scalp, with intense itching of lesions. The presence of follicular eruptions in the beard area (folliculitis barbae) was documented when observed.

The data were analyzed using the SPSS IBM, version 22.0 (Armonk, NY). Descriptive statistics were used. Continuous variables such as age when normally distributed were be represented by mean and standard deviation and when not normally distributed as median and interquartile range. Categorical variables were presented as frequencies and percentages. Categorical variables of two independent groups were compared using Fishers' exact test. P value was considered statistically significant at (P < 0.05).

  Results Top

A total of 307 participants were seen during the study period: 100 males and 207 females. [Table 1] shows the age distribution of the male participants. Seventy-five percent were between the fourth and seventh decades of life (age 30–60 years). Most of the respondents had a primary or secondary level of education.
Table 1: Age distribution of the male participants

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[Table 2] shows the haircare practices and history of follicular eruptions (bumps) amongst all the male participants. Fifteen male participants had a prior history of FK on the scalp and eight had received previous treatment for it. Clinical evaluation of the 207 female participants showed that none had a history and features of FK. [Table 3] shows the age distribution and the hair care practices in the male participants with FK. The median age of participants with folliculitis barbae was 43 (IQR 39, 51).
Table 2: History of hair care practices and follicular eruptions (bumps) in all male respondents

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Table 3: Hair care practices among patients with folliculitis keloidalis and folliculitis barbae

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Examination revealed the presence of FK in 4 respondents (4%): 3 had only the scalp affected and one had both the scalp and the beard area involved. There was follicular barbae (erythematous papules in the beard area) in six participants. None of the respondents presented with keloidal lesions on the scalp and the beard area. [Figure 1],[Figure 2],[Figure 3] show follicular papules at the nape. FK was associated with hair loss in all respondents with FK. There was associated seborrheic dermatitis (scaling or flaking) in 2 of the four participants with FK. There was a significant relationship between prior history and treatment of bumps and the presence of follicular keloidalis on examination (P = 0.003) [Table 4]. Two of the 15 participants with a history of bumps on the scalp presented with FK; and two of the 24 participants with rashes after a haircut presented with FK; and these were not statistically significant [Table 5]a and [Table 5]b.
Figure 1: Follicular papules at the nape of the neck

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Figure 2: Extensive Follicular papules at the nape

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Figure 3: Follicular papules with excoriations

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Table 4:

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Table 5:

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  Discussion Top

FK and folliculitis barbae are well known among Nigerian males and their hairdressers (barbers). It is popularly called “bumps” as has been confirmed by Ogunbiyi et al. in a local study.[12] Our study reported FK with an overall prevalence of 1.3% among all participants and 4% in the male participants.[12] Community-based study of FK is rare in Africa and only two studies with the prevalence of 2.7% in Nigeria and 3.5% in South Africa are available; in which participants were only males.[11],[12]

FK is regarded as a disorder of hair grooming practices among African males, particularly related to very low haircuts and frequent cutting of the hair with the shaping of the edges with hair clippers and razors.[19] This study noted that about 70% of the responders cut or shave their hairs weekly or bimonthly; about 97% use razors and hair clippers, and 54% shape their scalp at the edges. FK was not associated significantly with the shaving of the hair in this study, unlike in other studies.[8],[9],[10],[11] The total number of participants in this community-based study with FK is very low, hence an inference cannot be made on this result. In the hands of the inexperienced and in the setting of low socioeconomic conditions, there is a very high probability of precipitation and aggravation of the lesions with friction and pressure associated with the hair grooming practices of African males.[19] One suggested preventive measure is to avoid low cut and shaving of hair by males, which will severely limit hair grooming practices available for African men.[19]

The dominant hypotheses for FK include transepidermal elimination (extrusion of degenerated hair follicles and foreign body reaction), foreign body reaction to ingrowing hairs and mechanically induced folliculitis, all of which have not been completely proven by epidemiologic and histologic studies.[20] These theories have all been explained by the hair grooming practices in African males.

The absence of lesions in the female participants is expected given the rarity of FK in females. Hair grooming practices in females differ significantly from males and have reduced tendency to mechanical injury and folliculitis from frequent cutting and shaving of hair edges compared to males. George et al. proposed the association of FK with a high level of androgens, which is rare in premenopausal females.[17] Hair grooming in African women includes dreadlocks, weaves, braids, cornrows, use of hair extensions and chemical relaxers which predispose them to other scalp disorders such as traction alopecia, central cicatricial centrifugal alopecia, contact dermatitis, and chemical alopecia often from prolonged tension on the hair roots and destruction of the chemical structures of the hair.[21]

This study noted that participants with FK presented only with keratotic and follicular papules, and none with keloidal scars or other complications in this series. Studies from Nigeria which are hospital-based have documented FK at all stages: Keloids, scars, abscesses, and sinuses with bacterial infection.[7],[8],[10] Our study noted that 15% of respondents had FK in the past and 8% had received a form of treatment. This is likely because most people in Nigeria practice self-medication, visiting chemists and community pharmacists where they can get practically any drug over the counter, and many patronize alternative practitioners for herbal or traditional therapy.[22],[23]

Ogunbiyi noted that respondents in a community study believed that FK was infective in origin, was hereditary and resulted from poor shaving techniques. Self-medication by individuals with FK may be responsible for the nonprogression to the keloidal stages noted in the study.[12] “Barbers” and male hairdressers have been documented to provide first-line treatment for those who patronize them and have been noted to be important in the provision of health information and public health interventions in the management of hair disorders in males.[12],[19] Unfortunately, the dermatologist is only sought after when there is no response to the various therapies they have used. It is our belief that the apparently low prevalence of severe disease in hospital studies can be attributed to the high rate of self-medication by those affected.

Limitations to this study include the low number of participants available for study occasioned by the need to stop the study because of the COVID-19 pandemic, hence the clinical findings could not be fully characterized. Our population consists of mainly traders in the market and we may have excluded other professionals with risk factors for the development of AKN.

  Conclusion Top

This study noted a low prevalence of follicular keloidalis with all individuals presenting at the early stage with keratotic/follicular papules, which we posit was from regular self-treatment with antibiotics and triple action creams (consisting of a potent steroid, an antifungal agent, and an antibiotic) commonly sold in the market and over the counter for the treatment of skin and scalp disorders.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Knable AL Jr., Hanke CW, Gonin R. Prevalence of acne keloidalis nuchae in football players. J Am Acad Dermatol 1997;37:570-4.  Back to cited text no. 2
Ogunbiyi A, George A. Acne keloidalis in females: Case report and review of literature. J Natl Med Assoc 2005;97:736-8.  Back to cited text no. 3
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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