Pseudo-acne fulminans associated with oral isotretinoin

Acne fulminans is a rare and serious condition characterized by the sudden onset of nodular and ulcerative acne lesions associated with systemic symptoms. It has been recognized a subset of patients with a sudden worsening of acne, often during treatment with oral isotretinoin, but without the strong presence of systemic involvement. Recognized by some authors as "pseudo-acne fulminans" or " acne fulminans sine fulminans," we report a case with these features in order to draw attention to the recognition and early management of this manifestation.     

A case of acne fulminans in a patient with ulcerative colitis successfully treated with prednisolone and diaminodiphenylsulfone: a literature review of acne fulminans, rosacea fulminans and neutrophilic dermatoses occurring in the setting of inflammatory bowel disease

A 19-year-old Japanese man had been treated for ulcerative colitis for 2 years. He was admitted to our hospital with nodulocystic inflammatory papules and pustules on his face and chest, high-grade fever, arthralgia and general malaise. A biopsy specimen from a pustule showed prominent infiltration of neutrophils in the epidermis and dermis, particularly around hair follicles. We made a diagnosis of acne fulminans. The systemic administration of prednisolone at 30 mg daily for 1 week immediately improved his skin lesions and other symptoms; however, during tapering of prednisolone at 20 mg daily, skin lesions flared up. The addition of oral diaminodiphenylsulfone improved the skin lesions. Although there have been a few reports of acne fulminans associated with Crohn's disease, this is the first case report of acne fulminans in a patient with ulcerative colitis. It is noteworthy that the addition of diaminodiphenylsulfone was effective for treating the relapse of acne fulminans in this case.     

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 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.     

Levamisole treatment of acne fulminans (author's transl)

In two young patients levamisole 150 mg twice weekly led to a rapid and long-lasting improvement of their acne fulminans. The sudden deterioration of acne vulgaris leading to acne fulminans is possibly due to a temporary immunodepression.     

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—report of a case with polyarteritis

A case of acne fulminans with radiological features of an arthritis is reported. This recently described association is reviewed. Acne fulminans (Goldschmidt, Leyden & Stein, 1977) is a rare but well characterized disorder consisting of a highly inflammatory form of acne associated with a variety of systemic features. Recent reports (Hunter & Hesinger, 1980; Davis et al., 1981; Cros, Gamby & Serratrice, 1981) have highlighted the presence of radiological changes accompanying joint symptoms in patients with acne fulminans. We report a further case with these associations.     

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.     

Unilateral sacroiliitis associated with systemic isotretinoin treatment

Background Acne fulminans is the most severe form of inflammatory acne characterized by the acute onset of inflammatory nodules and plaques, most commonly on the chest and the back. The lesions undergo rapid suppuration, leaving ragged hemorrhagic ulcers. Typically, it affects adolescent males with a history of mild to moderate acne. The affected patients often have constitutional symptoms such as fever, malaise, arthralgias, and myalgias. Leukocytosis is commonly associated. Sacroiliitis is reported in 21% of acne fulminans patients in association with arthritis and in a few cases it is reported during isotretinoin treatment, suggesting the drug triggering. Conclusion We report a case of a young male patient in whom the induction of acne fulminans by systemic isotretinoin was associated with unilateral sacroiliitis.     

Acne fulminans triggered by isotretinoin therapy]

An 18-year old male patients with tetracycline-resistant acne vulgaris was prescribed isotretinoin in daily doses of 0.5 mg/kg. Ten days later, he developed an acute episode of acne fulminans which was regressive. Subsequently, two attempts were made at reintroducing isotretinoin; the first one was followed by a new episode of acne fulminans and the second one, by ordinary myalgias, while the patient was still under corticosteroid therapy. A search in the literature yielded 14 cases of acne fulminans that had possibly been induced by isotretinoin. Doses and intervals between medication and acute manifestations varied, and the responsibility of isotretinoin was seldom demonstrated. Associations with erythema nodosum myalgias and arthralgias have been described. This rare adverse effect of isotretinoin therapy must be known. Its course and treatment are not different from those of ordinary acne fulminans.     

Isotretinoin‐induced acne fulminans without systemic symptoms with concurrent exuberant granulation tissue

Acne fulminans is a severe form of acne characterized by painful, inflammatory nodules that progress into ulcers and concurrent systemic symptoms. Treatment of acne with isotretinoin can precipitate a syndrome called isotretinoin‐induced acne fulminans without systemic symptoms. An exuberant granulation tissue response, another known adverse event associated with isotretinoin, can occur concurrently, inhibiting wound repair and complicating treatment. We report a case of isotretinoin‐induced acne fulminans without systemic symptoms with exuberant granulation tissue response that was treated successfully with topical clobetasol ointment.     

Two Cases of Musculoskeletal Syndrome Associated with Acne

Abstract: We report two cases of musculoskeletal syndrome (myalgia, arthralgia, arthritis, hyperostosis) that developed in male adolescents who had severe acne (acne conglobata and acne fulminans). In both patients the hyperostosis of the right clavicle aroused the suspicion a bone tumor or osteomyelitis, which was excluded by histologic examination. Radiologic and laboratory characteristics of musculoskeletal syndrome associated with acne conglobata and acne fulminans are reviewed as well as isotretinoin therapy. The problems of differential diagnosis are also discussed.     

Familial acne fulminans

We report a patient of acne fulminans with arthralgia whose sister presented with the same disease at an identical age 10 years earlier. The two affected siblings in our family also had identical HLA phenotypes which further supported the role of genetic susceptibility in acne fulminans.     

The treatment of acne fulminans: a review of 25 cases

The treatment of acne fulminans has been difficult. It is difficult to perform a controlled treatment trial due to the rarity of the complication. However, it is possible to compare four different therapeutic regimens which have evolved with time in the management of 25 patients over a period of 25 years. Oral antibiotics produced a slow response in the resolution of acne and systemic symptoms. The addition of a systemic steroid produced a quick resolution of systemic features, but the time until resolution of the acne was longer than when it was used in combination with oral isotretinoin. The protocols which used a combination of prednisolone and isotretinoin led to faster control of systemic features as well as clearance of acne when compared with other protocols. This was particularly so if the oral steroid was used sooner rather than later. We conclude that the preferred treatment of acne fulminans is oral prednisolone 0.5-1 mg/kg daily for 4-6 weeks (thereafter slowly reduced to zero) with oral isotretinoin being added to the regimen at the fourth week, initially at 0.5 mg/kg daily and gradually increased to achieve complete clearance.     

Systemic inflammatory reactions and extracutaneous manifestations of acne vulgaris

166 patients suffering from acne of different severity were examined with regard to associated systemic manifestations. 74 of the patients showed acne conglobata, 12 acne tetrade, 11 acne fulminans, and 69 acne papulopustulosa. Subjective symptoms like weakness, fever, and arthralgia, as well as unspecific serological inflammatory parameters and internal symptoms were taken into consideration. Acne papulopustulosa was not associated with any internal symptoms. Such extracutaneous reactions were observed, however, in severe forms of acne as in acne tetrade or acne conglobata (41% vs 17%). Acne fulminans revealed musculoskeletal manifestations and severe inflammatory signs in the blood. The high rate of kidney involvement with severe inflammatory types of acne was alarming. Three patients developed on acute glomerulonephritis, which evolved into a chronic form in two patients.     

Acne fulminans concomitant with vasculitis-like symptoms mimicking Henoch-Schoenlein purpura

Acne fulminans is a severe form of acne vulgaris accompanied by systemic symptoms. A 17-year-old Chinese boy presented with an outbreak of necrotic lesions on his face eight days after the onset of palpable purpura, arthralgia, fever, abdominal pain, and proteinuria. He was successfully treated with oral prednisolone and isotretinoin. Vasculitis-like symptoms are rarely reported in acne fulminans; therefore, the physician needs to maintain awareness of this uncommon presentation.     

Klinische Formen der Akne

Acne is a very common dermatosis with characteristic clinical features. It is a polymorphic disease. The clinical expression ranges from non-inflammatory closed and open comedones to inflammatory papules, pustules, and nodules. Most patients have a mixture of non-inflammatory and inflammatory lesions, although some have predominantly one or the other. Acne varies in severity from a very distressing, socially disabling disorder to a state that has been regarded as physiological by some authors. The most severe forms of acne are acne fulminans and acne inversa. Although acne may occur in all age groups, it is most prevalent during adolescence. It is not known why acne subsides in most patients but persists into adulthood in some. Certain medications may be associated with provocation, perpetuation, or exacerbation of pre-existing acne or with acneiform eruptions. Acne-like disorders include rosacea, pseudofolliculitis barbae, and other conditions that share clinical features with acne.     

Fulminant acne: therapy with 13-cis-retinoic acid and indomethacin

Young men with mild acne vulgaris may rarely experience a very acute exacerbation with ulceration and necrosis of the lesions accompanied by fever, malaise, loss of weight, often by polyarthritis, and occasionally by erythema nodosum. Elevated sedimentation rate and marked leucocytosis are characteristic; microhematuria is often observed. This condition has been called acne fulminans. We report on a young male patient suffering from severe acne fulminans. Systemic 13-cis retinoic acid (Roaccutan, Accutane) and indomethacine (Amuno) treatment rapidly improved the skin and joint lesions. Intracutaneous tests with viral, bacterial, and fungal antigens before and during treatment suggest a temporary cellular immune defect.     

Acne fulminans: investigation of acute febrile ulcerative acne.

Eight cases of acne fulminans (acute febrile ulcerative acne) are compared with 13 previously reported cases. This rare disorder of male teenage patients is characterized by the sudden appearance of highly inflammatory, tender, ulcerative and crusted lesions on the back, chest, and face: it is one of the most scarring acute dermatologic disorders of young patients. At the onset of the disease, all patients showed febrile temperatures and marked leukocytosis; other systemic symptoms occurred with varying frequency. Polyarthralgia was noted in half of our series. Investigations of potential trigger mechanisms (eg, septisemia due to Corynebacterium acnes, immunologic defects, altered polymorphonuclear leukocyte function, Shwartzman phenomenon) did not yield any clues regarding the pathogenesis of this disease. Clinical and laboratory findings suggest that acne fulminans is not directly related to acne conglobata.     

Acne of the fulminans type following testosterone therapy in three excessively tall boys

Ulcerative acne was observed in three boys who underwent long-term treatment with high doses of testosterone for excessively tall stature. Even after withdrawal of testosterone therapy, this devastating type of acne still persisted for several months. After starting isotretinoin treatment, two cases progressed to full-blown acne fulminans with systemic manifestations. In these two cases, oral isotretinoin therapy induced multiple lesions of hyperproliferative granulation tissue resembling pyogenic granuloma. Topical steroid treatment proved to be beneficial for this adverse effect. Systemic corticosteroid treatment was administered in one case. High testosterone levels during puberty may be an important trigger mechanism of acne fulminans and may explain why this disease almost exclusively affects male adolescents.