Acne fulminans

What is acne fulminans?

Acne fulminans is a rare and very severe form of acne conglobata associated with systemic symptoms. It nearly always affects adolescent males.

 

 

 

What are the clinical features of acne fulminans?

Acne fulminans is characterised by:

• Abrupt onset
• Inflammatory and ulcerated nodular acne on chest and back, which is painful
• Bleeding crusts over the ulcers on upper trunk
• Severe acne scarring
• Fluctuating fever
• Painful joints, including sacroiliac joints in 20% of cases, ankles, shoulders, and knee joints
• Malaise (i.e. the patient feels unwell)
• Loss of appetite and weight loss
• Enlarged liver and spleen.

Tests typically reveal:

• Anaemia (lowered haemoglobin count)
• Raised white blood cell count
• Raised erythrocyte sedimentation rate (ESR) and C-reactive protein levels
• X-rays may show osteolytic bone lesions.

What causes acne fulminans?

Acne fulminans has been associated with increased androgens (male hormones), autoimmune complex disease and genetic predisposition. It may be related to an explosive hypersensitivity reaction to surface bacteria (Cutibacteria acnes). Acne fulminans may be precipitated by:

• Testosterone and anabolic steroids (legally prescribed or illegally taken to enhance muscle growth)
• Oral isotretinoin.

The syndrome SAPHO (Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis) may be a serious complication of acne fulminans.

What is the treatment for acne fulminans?

Patients with acne fulminans should consult a dermatologist urgently. Management can prove difficult, and several medications are usually required for several months or longer. These may include:

• Systemic corticosteroids such as prednisone (20–60 mg/day)
• Anti-inflammatory medications such as salicylates (aspirin)
• Dapsone 50–100 mg/d
• Ciclosporin
• High doses of oral antibiotics such as erythromycin (2 g/day) for secondary infection
• Isotretinoin commenced in low dose after control has been obtained with systemic steroids
• Tumour necrosis factor-alpha (TNF-α) inhibitors, such as infliximab.

Topical acne medications are unhelpful.