PMC8462837_01
A 43-year-old male with 12 years history of scalp folliculitis that progressed into AKN. BMI 35 kg/m2. Fitzpatrick skin type 5. (A) Initial dermatology assessment. Dissecting scalp folliculitis; recommended rifampin (300 mg oral BID), clindamycin (300 mg oral BID), clindamycin lotion daily and triamcinolone cream. (B) AKN with firm thickened scarring on occipital scalp, areas of crusting, no active drains. Recommended doxycycline (100 mg oral BID), rifampin (300 mg oral BID), lidex solution and clindamycin lotion BID and intralesional injections of triamcinolone. (C) Progression of AKN lesion. Pink, firm thickened scarring plaques and purulent drainage. Patient continued follow-up in Dermatology clinic for 15 months and treated with Isotretinoin (40 mg oral daily) and additional intralesional injections of triamcinolone. (D-F) Preoperative assessment by Plastic Surgery. A 12 x 12 cm occipital infected fibrotic mass with multiple ingrowing hairs and points of purulent drainage.
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Initially managed by dermatologist with oral rifampin and clindamycin along with topical clindamycin lotion and triamcinolone cream (Figure 1(A)). Patient developed a large AKN lesion with firm thickened scarring plaques on occipital scalp with areas of crusting and no active drainage (Figure 1(B)). Patient continued follow-up in dermatology clinic for 15 months where he was also treated with isotretinoin and additional intralesional injections of triamcinolone (Figure 1(C)). During the first assessment by plastic surgery team, patient had a 12 x 12 cm infected and fibrotic occipital mass with multiple ingrowing hairs and points of purulent drainage (Figure 1(D-F)).
PMC8462837_02
A 65-year-old male with history of AKN for at least 9 years. BMI 27 kg/m2. An 18 x 8 cm fluctuant AKN lesion on the occipital area with multiple ingrowing hairs, hemorrhagic crusts, cysts and purulent drainage from several sites. Fitzpatrick skin type 5. (A) Initial assessment in outpatient clinic. (B) Postoperative day 6 of 18 x 8 cm AKN excision. (C) Postoperative day 22; wound getting smaller, more superficial and well vascularized. Dark spot in the middle corresponds to overlying tissue of suture ligation of large arterial perforator. (D) Postoperative day 51; intraoperative view prior to skin graft procedure. (E) Initial dressing on day 6 after placement of split thickness skin graft. (F) Local condition one month after skin graft.
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In long-term follow-ups, our patients were asymptomatic with stable coverage and areas of alopecia significantly smaller compared to that in the original AKN lesions (Figures 2(F), 3(F) and 4(C)).
PMC8462837_03
Post-excisional course. (A) Postoperative day 4; first postoperative assessment in outpatient clinic. (B) Postoperative day 39; open wound getting significantly smaller, more superficial and well vascularized. (C) Postoperative day 49; local condition during the second surgical procedure. Open area still reducing in size, smooth and well vascularized granulation tissue with small area of epidermal cells spreading out on surface. (D) Six days after second surgery with the bolster dressing in place. Skin graft was harvested from upper back. (E) Meshed split thickness skin graft after dressing removal the same day. (F) Long term follow-up 3 months after skin graft.
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For patients No. 1 and No. 2, the post-excisional wounds were left widely open and packed with Dakin's solution-soaked gauze and secured with ABD pads, kerlix and tubular elastic net (Figures 2(A) and 3(B)). During the postoperative period, wounds exhibited significant improvement reducing the size and depth and developing well-vascularized granulation tissue on surface in preparation for skin graft (Figures 2(B,C) and 3(C,D)). Afterward, the position of the bolster dressing was reinforced with a 2-0 Prolene suture that sequentially grabbed the skin in one side, passed through the xeroform at the top of the bolster dressing before it reached the other side of the skin (Figure 2(D)). In both cases, we obtained nearly 100% skin graft take with a well vascularized graft (Figures 2(E) and 3(E)). In long-term follow-ups, our patients were asymptomatic with stable coverage and areas of alopecia significantly smaller compared to that in the original AKN lesions (Figures 2(F), 3(F) and 4(C)).
A 65-year-old male with history of AKN for at least 9 years. BMI 27 kg/m2. An 18 x 8 cm fluctuant AKN lesion on the occipital area with multiple ingrowing hairs, hemorrhagic crusts, cysts and purulent drainage from several sites. Fitzpatrick skin type 5. (A) Initial assessment in outpatient clinic. (B) Postoperative day 6 of 18 x 8 cm AKN excision. (C) Postoperative day 22; wound getting smaller, more superficial and well vascularized. Dark spot in the middle corresponds to overlying tissue of suture ligation of large arterial perforator. (D) Postoperative day 51; intraoperative view prior to skin graft procedure. (E) Initial dressing on day 6 after placement of split thickness skin graft. (F) Local condition one month after skin graft.
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In long-term follow-ups, our patients were asymptomatic with stable coverage and areas of alopecia significantly smaller compared to that in the original AKN lesions (Figures 2(F), 3(F) and 4(C)).
A 30-year-old male, BMI 48.5 kg/m2, Fitzpatrick skin type 5, giant AKN. (A) Intraoperative view of 25.5 x 15 cm 'keloid-type' lesion treated with wide local excision, complex partial wound closure and split thickness skin graft. Specimen weight: 815 g. (B) Initial dressing change. Donor site and STSG during first postoperative visit in outpatient clinic (postoperative day 6). Partial take of the skin graft treated with local care and systemic antibiotics. Of note, there are multiple skin openings on the area from underlying epidermal inclusion cysts; superficial biofilm also noticed. (C) Long-term follow-up (postoperative day 61). Local condition on grafted area and donor site.
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Subsequently, the patient was referred to plastic surgery clinic due to the disabling condition generated by a giant 25.5 x 15 cm AKN lesion (Figure 4(A)). In case No. 3, a partial skin closure with 3-0 vicryl sutures followed by immediate split thickness skin graft (STSG) was performed due to the magnitude of the ablative wound (specimen weight: 815 g) and concerns of inappropriate wound management in outpatient setting (Figure 4). Despite partial graft take likely secondary to the presence of multiple epidermal inclusion cysts and bacterial contamination on the donor site, the skin coverage was reached satisfactorily with local care (daily dressings with Dakin's solution as described above) and without additional surgical interventions (Figure 4(B,C)).
Pathology assessment of case No. 1. (A) Cross section of surgical specimen. Multiple, ragged, necrotic, hair-bearing lesions ranging from 0.1 x 0.1 x 0.1 cm to 6.5 x 5.2 x 4.3 cm, spanning the skin surface. (B) Details of necrotic, hair-bearing intralesional cavities. (C) Widened hair follicle surrounded by dense inflammatory process and dermal fibrosis, and overlying scale crust; 20x magnification. (D) Scattered hair shafts within a fibrotic dermis and dense acute and chronic inflammation; 40x magnification.
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Surgical specimens revealed multiple, necrotic and hair-bearing intralesional cavities of variable sizes spanning the skin surface (Figure 5(A,B)). There was background evidence of scarring within the dermis with dense collagenous tissue arranged parallel to the skin surface associated with numerous blood vessels (Figure 5(C,D)).