John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442

Acne Necrotica Miliaris

Patient Information Sheet

Acne refers to an inflammation of the hair follicle. Necrotica means that the inflammation is so severe that it kills the affected hair follicle. Miliaris refers to a millet, a European term for a small seed.

Acne necrotica miliaris is a condition that produces pimples mostly in the scalp along the hairline and especially the back of the head and neck. It can also occur on the face, nose, and chest, but mostly it affects the scalp. These are especially frustrating pimples because it is hard to squeeze anything out of them. You can't see them very well when they are on the back of the neck. That makes them more annoying. They tend to be persistent. Most of the time, there are only a few pimples, a dozen or less. But there can be more.

I performed extensive searches of the medical literature in 1990 - 2010 and in 2018 on the Medline database at the National Library of Medicine. Very little has been published about acne necrotica miliaris. In fact, I was surprised how little is known about this condition. It is an inflammation by lymphocytes (a type of white blood cell) around hair follicles. As it progresses, the lymphocytes invade the hair follicle, kill the cells of the hair root and wall of the hair follicle, and kill the hair. It is an intense inflammation. It does not cause baldness. It is not an infection. Other than that, little is known about it.

Acne necrotica miliaris tends to be stubborn and may persist or come and go for ten years or more. I have observed that stress makes it worse. Many people with acne necrotica miliaris have jobs that place a lot of responsibility on them. It is a little more common in middle-aged executives. There is no cure for acne necrotica miliaris, but, usually improvement and control are possible.

I have had the best results by treating people with minocycline pills. Usually, one 50 mg. pill a day is enough. One 50 mg minocycline pill a day is not enough to kill bacteria. So that's not how it works. It seems to control inflammation in hair follicles.

Minocycline a super tetracycline that gets into the skin more selectively, about 10 times better. So instead of taking 250 mg or 500 mg of tetracycline, usually 50 mg of minocycline is enough.

A warning about minocycline. If it makes you nauseated or dizzy, blame the medicine and stop it. Let me know. Cheap generics have appeared on the market that I think have impurities because of sloppy manufacturing. In all fairness to some foreign manufacturers, around 2017, they seemed to be making a safer product.

Alternative Treatments of Acne Necrotica Miliaris

  1. Bactericidal dose of antibiotic such as erythromycin for one month (method of Doctors Walter and Dorinda Shelley). That is a dose high enough to kill bacteria.
  2. Accutane- Australian study.
  3. Topical steroid solution such as Lidex (fluocinonide). Apply one drop twice a day as needed. This is a helpful emergency treatment. Method of Dr. Tkach.
  4. Ketoconazole- an antifungal pill. I have not tied this.
  5. Intralesional Kenalog- this is a useful emergency treatment when you reach your wit's end with the condition or you get one or two very stubborn pimples. It does not produce long-lasting improvement. I inject a small amount of dilute cortisone into the pimple. That makes it better in about 2 to 4 days in about 80% of cases.


My 2018 literature searches turned up a few articles on Acne Necrotica. But, I think that is something different. The sores look more severe and widespread. There seems to be trend to rename that condition "necrotizing lymphocytic folliculitis." There is also confusion about what insurance diagnosis code to use.

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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