Having pimples in back head lower part only they come and go

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pimples lower back of head occipital scalp recurring causes treatment

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Here is a thorough breakdown of what's going on and what you can do about it.

Pimples on the Lower Back of the Head (Occipital/Nape Area)

Pimples that come and go specifically on the lower back of the head (occipital scalp / nape of the neck) are very common. There are a few distinct conditions that cause this, and they're worth telling apart.

Most Likely Causes

1. Scalp Folliculitis (Most Common)

Bacterial infection of hair follicles, usually from Staphylococcus aureus. Shows up as:

Small red or pus-filled bumps around individual hair follicles
Itching, sometimes mild tenderness
They come and go, especially with sweating, helmet use, or poor scalp hygiene

The lower occipital area is a hotspot because sweat accumulates there, especially under collars or helmets.

2. Acne Keloidalis Nuchae (AKN)

A chronic inflammatory folliculitis specifically of the posterior neck and occipital scalp. Key facts from dermatology textbooks:

Starts as inflamed follicular papules or pustules on the posterior neck and occipital scalp
More common in Black men, but can affect others
If left untreated over time, the bumps can turn into keloid-like hard plaques and cause scarring/hair loss
Triggered or worsened by: close shaving, high collars, helmets, friction, and possibly androgens

- Dermatology 2-Volume Set 5e (Acne Keloidalis section)

3. Acne Cosmetica

Hair products (oils, conditioners, waxes, pomades) that run down to the nape area can clog follicles and cause recurring pimples. Very common and easy to fix by changing products.

4. Folliculitis Decalvans (Less Common, More Serious)

A scarring folliculitis associated with S. aureus. Can affect the nape/occipital area. Patients often feel itching, burning, or pain. If bumps are accompanied by patches of hair loss, this needs dermatologist evaluation.

- Fitzpatrick's Dermatology (Folliculitis Decalvans section)

What Makes Them Come and Go?

The recurring pattern is typical and usually driven by:

Sweating (exercise, hot weather, tight headwear)
Hair product buildup not fully washed out
Friction from shirt collars, helmets, caps
Hormonal fluctuations (androgens increase sebum production)
Stress (flares inflammation systemically)
Incomplete treatment - bacteria suppress but don't fully clear

What to Do

At home:

Wash your hair/scalp regularly, especially after sweating - pay extra attention to the lower back of the head
Use a medicated shampoo 2-3x per week with one of these active ingredients:
- Ketoconazole 2% (antifungal, helps if there's a fungal component)
- Zinc pyrithione (antibacterial + antifungal)
- Salicylic acid (unclogs follicles)
Avoid heavy hair oils or pomades near the nape
Switch to a breathable, loose collar and wash pillowcases frequently
Do not pick or squeeze the bumps - this introduces more bacteria and risks scarring

When to see a doctor (dermatologist):

Bumps are painful, large, or filled with pus that keeps coming back
You notice any hair loss in the area - this may indicate folliculitis decalvans or AKN with scarring, which needs prescription treatment
Home care doesn't improve things in 4-6 weeks
Bumps are hardening or leaving permanent marks

Medical treatments a doctor may prescribe:

Topical antibiotics (clindamycin, mupirocin)
Topical or intralesional corticosteroids (for AKN/inflammation)
Oral antibiotics (minocycline, doxycycline, rifampin + clindamycin combination for persistent cases)
Retinoids (for chronic cases)
Laser hair removal (for AKN - Nd:YAG 1064nm laser is used even in darker skin tones)

Summary

Feature	Likely Cause
Small, itchy, recurring pimples only	Folliculitis / Acne cosmetica
Hard bumps that don't fully resolve	Early AKN
Any hair loss + bumps	Folliculitis decalvans / AKN - see dermatologist
After using new hair product	Acne cosmetica
Worsens with helmets/tight collars	AKN / Friction folliculitis

Since yours come and go without forming hard persistent lumps, this sounds like recurring scalp folliculitis - very manageable. Start with a ketoconazole or zinc pyrithione shampoo used 3x/week, avoid friction from collars/caps, and wash the area after sweating. If it keeps coming back after 6 weeks of this, visit a dermatologist for a bacterial culture and targeted treatment.

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