Acne fulminans and isotretinoin: case report

Acne fulminans (AF) is a rare disorder, the most severe form of the entire clinical spectrum of acne. It is characterized by emergence of painful inflammatory nodules that turn into ulcers, concomitant with systemic manifestations. It can be induced by isotretinoin and some authors believe that the occurrence of this condition is dose dependent. The treatment is controversial and there is no consensus up to this time. A case of this rare disease, developed during use of isotretinoin in low doses, is presented.     

Acne fulminans and erythema nodosum during isotretinoin therapy responding to dapsone

Acne vulgaris is very common, 85% of teenagers being affected at any one time. In most cases, the disease is mild and patients do not present to the dermatologist. Most are instead treated with over-the-counter products and conventional treatment such as peeling agents or topical and systemic antibiotics. Isotretinoin has revolutionized the treatment of severe acne unresponsive to oral antibiotics. Explosive and very severe acne such as pyoderma faciale, acne conglobata and acne fulminans are rare, the features that distinguish acne fulminans from the other conditions being systemic upset with fever, joint pain, malaise and leucocytosis,^1–3 while there have been two reports of the condition associated with erythema nodosum.^4,5 The recommended treatment for acne fulminans is a combination of oral steroids and systemic antibiotics, isotretinoin probably not being the treatment of choice.⁶ We now report a patient who developed acne fulminans and erythema nodosum within 3 weeks of starting isotretinoin and then responded to dapsone without oral steroids.     

Acne fulminans]

Acne fulminans is a rare disorder of male teenage patients. The disease is characterized by the sudden appearance of highly inflammatory, tender, ulcerative and crusted lesions on back, chest and face. At the onset of the disease all patients show febrile temperature, leucocytosis, increased sedimentation rate and frequently polyarthralgia. The reported case showed typical lesions and distribution, fever, leucocytosis, elevated sedimentation rate, anemia, a decrease in albumin and an increase in alpha 2-globulin. Intradermal skin tests (delayed reactivity) showed marked decrease responses. Systemic treatment with antibiotics (ampicilline, tetracycline) with concomitant topical therapy was effective.     

Acne fulminans

Acne fulminans is a syndrome of fulminant, necrotizing acne associated with bone lesions, constitutional symptoms, and laboratory abnormalities. A case report of an adolescent male with acne fulminans following withdrawal of isotretinoin and prednisone is presented.     

Acne fulminans 'sine fulminans'

Acne fulminans is characterized by the sudden onset of a severe, ulcerative acne associated with systemic features. Response to traditional acne therapies is poor. We have recognized a subset of patients with acne of a severity comparable to that of acne fulminans but with the absence of systemic involvement; we suggest modification of the treatment regimes used in this group.     

Acne fulminans (acute febrile ulcerative conglobate acne) treated with isotretinoin: a case report

A 16-year-old boy was treated for acne fulminans (AF) with isotretinoin when the acute inflammatory stage had been suppressed with oral corticosteroids. From our experience of this case and from our review of the literature, we recommend that isotretinoin should be withheld during the acute, inflammatory phase of AF in order to prevent exacerbation of the condition.     

Acne fulminans with bone lesions

We present 5 young men who developed acne fulminans. During the acute, febrile illness, all had musculoskeletal symptoms, and X-ray and bone scan examinations revealed that 4 of the patients had osteolytic bone lesions. The disease was resistant to various antibiotics and one patient needed surgical trepanation of the sternum. No evidence of sepsis or bacterial osteomyelitis was found, as all bacteriological cultures proved negative and the tissue reaction was unspecific. The dermatopathogenetic origin of bone lesions in the present patients seems evident, but speculation that the etiology depends on immune mechanisms remains open.     

Acne fulminans with osteolytic lesions

Multifocal lytic bone lesions were found in a patient with a severe form of acne. The clinical presentation was suggestive of "acne fulminans." Propionibacterium acnes was isolated from a subculture of bone tissue. The association of acne fulminans and osteolytic lesions is rare and the pathophysiology is unknown. However, the use of corticosteroids for systemic effect combined with local measures seems to give excellent treatment results.     

Acne fulminans following use of anabolic steroids

The main stimulant for the use of anabolic agents by competitive athletes is their effect on the quantity, structure, and power of the muscles, although an actual increase in efficiency is most doubtful. This effect has to be purchased with a number of possible side effects including acne or acneiform lesions - an interesting aspect from the dermatologic point of view, since androgens may have an etiopathogenetic significance in this disease. We report on a 23-year-old male patient (competitive javelin thrower) who developed acne fulminans while using anabolics and vitamin B preparations. The temporal correlation between the onset of the skin lesions and the intake of the drugs suggests that the drugs - either alone or in combination - may be responsible for the skin eruptions. We discuss the case in detail referring to the literature.