How do you approach treating patients with acne keloidalis nuchae who do not respond to a potent topical steroid or retinoid?

For mild disease, topical steroids and topical clindamycin solution alone or in combination with benzoyl peroxide wash or gel are recommended. It is also important to counsel patients to reduce friction to the area (usually the occipital scalp) and avoid cutting hair close to the skin. For moderate disease, without evidence of secondary bacterial infection, we use intralesional triamcinolone (5-40 mg/mL) every 4-6 weeks in addition to topical clindamycin solution twice daily. For a severe disease where there is evidence of honey-colored crusting, we recommend obtaining a bacterial swab to send for culture and starting a systemic antibacterial with anti-inflammatory properties (e.g. doxycycline or minocycline at 100 mg twice daily) along wit...

Very thorough and excellent answer!

Intralesional triamcinolone is quite effective at reducing the papules, and can be performed in separate sessions if there are a lot of lesions.

Topical numbing can be applied 1 hour prior to an appointment to help a little with the needle pricks. If there are larger plaques or nodules, then I often will inject with lidocaine first to allow intralesional steroid injection in multiple directions and depths

intermittent dose isotretinoin (for ex. 40mg 2 or 3 days a week) can be helpful in some cases and more easily tolerated

for severe disease, shave debulking + Superficial radiation therapy is an option but will likely kill off the hair follicles