Acne fulminans or acne maligna is a rare skin disorder presenting as an acute, painful, ulcerating, and hemorrhagic clinical form of acne. It may or may not be associated with systemic symptoms such as fever and polyarthritis. Acne fulminans may also cause bone lesions and laboratory abnormalities. Acne fulminans is often confused with acne conglobata. The condition generally is resistant to the usual acne antibiotics.
Acne fulminans is a rare skin disorder, and hence its etiology is not well understood. It is believed that acne fulminans may be triggered by the use of high doses of isotretinoin when initiating treatment in patients with severe acne. Also, it is believed that elevated levels of the male sex hormone, testosterone, may play a role in the pathogenesis. Anabolic steroids are known to increase levels of sebum and density of Propionibacterium acnes. Bodybuilders who use anabolic steroids develop acne fulminans within a very short time. It is believed that the density of P. acnes or related antigens trigger the immune system and lead to acne fulminans. There are others who believe that the condition may be autoimmune mediated because circulating immune complexes have been observed in some patients with acne fulminans.
Acne fulminans also has a genetic component, but the pattern of inheritance is not known. The skin disorder may be part of the synovitis acne pustulosis hyperostosis osteitis syndrome (SAPHO), pyogenic arthritis pyoderma gangrenosum and acne syndrome (PAPA), pyoderma gangrenosum acne and hidradenitis suppurativa syndrome (PASH), and pyogenic arthritis pyoderma gangrenosum acne and hidradenitis suppurativa syndrome (PAPASH).
Less than 200 cases are known. The disorder usually affects young males, mainly Caucasian, between 13 and 22 years of age. Most of these males have a prior history of acne. There are also isolated reports of acne fulminans in females. The condition has been reported globally, but its incidence seems to be declining.
Acne fulminans usually has a very sudden onset, and the acne is often ulcerating. Patients may also complain of fever and pain in multiple joints. They usually provide a history that the conventional antibiotics for treating acne did not work. Most patients mention that they did have acne in the past.
Acne fulminans is similar to acne conglobata with numerous inflammatory nodules on the trunk. The nodules are often painful to touch, ulcerated, hemorrhagic, and covered with crusts. Unlike acne conglobata, there are cysts and acutely inflamed lesions, but there are no polyporous comedones. Painful splenomegaly and erythema nodosum may be associated with systemic symptoms.
In acne fulminans with systemic symptoms, and because of bone and joint pain, many patients have a stooped over posture. The inflammatory arthralgia usually affects more than one joint; typically the knees, hips, and pelvis.
Because the disorder may be associated with systemic symptoms, the workup should include the following:
Because of bone and joint pain, imaging is frequently done. In the early stage, x-rays will only show reactive changes. About 50% of patients will demonstrate lytic lesion on a plain x-ray, and the bone scan may show multiple areas of increased uptake. The lesions are destructive and often resemble acute osteomyelitis. Cultures of these bony lesions are often negative.
The advised treatment for acne fulminans is a combination of corticosteroids and isotretinoin. Oral corticosteroids should be started first at high doses (0.5 to 1 mg/kg/day) for at least 2 weeks (at least 4 weeks if systemic symptoms) until lesions heal. Isotretinoin is then started. The initial dose of isotretinoin should be 0.1 mg/kg/day in association with corticosteroids for 4 weeks. If no flare is observed, the same dose of isotretinoin should be maintained for 4 more weeks, and corticosteroid doses are gradually tapered. Increasing isotretinoin doses should then be progressed to a minimum total dose of 120 mg/kg is recommended.
In patients who remain adherent, relapses are rare. If a relapse does occur, a repeat cumulative dose of isotretinoin at 150 mg/kg is recommended. The treatment with isotretinoin lasts for many months as the initial dose is low.
A recent review suggests that the use of additional high-potency topical corticosteroids may give a faster response. Once healing occurs, the lesions become smaller, less tender, and have a minimal inflammatory reaction. However, scarring is common in many cases.
Acne fulminans does not respond to the traditional antibiotics used to treat regular acne. Even when they are used, the response is slow and not complete.
In the last few years, anecdotal reports have appeared after use of biologics, such as etanercept and infliximab, in patients who are resistant cases. The response to these agents is effective and rapid. However, it is not known if biologics will work in all patients. Several other targeted biological agents have also been used to treat acne fulminans.
Pulsed dye laser has been used with moderate effectiveness, but side effects and pain remain an issue. Because the lesions are large, multiple treatments are required, and scarring and hypopigmentation are common complications.
Reports suggest that diaminodiphenylsulfone use may help ease the symptoms of acne fulminans in patients with ulcerative colitis.
Combinations of prednisone with dapsone or cyclosporine have also been tried with success.
Finally, these patients are best managed by a dermatologist and an internist. Women of childbearing age should use great caution when using retinoids, as these agents are teratogenic. There is a registry of all patients who are prescribed retinoids. All women who are prescribed isotretinoin should avoid getting pregnant for at least one month after the drug is discontinued.
Acne fulminans is a devastating systemic disorder with severely disfiguring skin lesions. The majority of patients are affected negatively be the poor cosmesis. Their quality of life is altered, and they are not able to participate in sports or social activities. Many become withdrawn and isolated. Thus, it is vital to offer psychosocial counseling to them. Many of these patients will benefit from mental health treatment and the use of antidepressants. Suicidal ideation is very common in these patients and close follow up with a psychiatrist is highly recommended. The use of retinoids has not been shown to worsen the risk of depression or suicidal ideation.
The patient also has to be educated on the skin disorder and avoidance of triggering agents. The skin should be kept clean and dry, smoking should be discontinued, and one should refrain from applying unproven remedies like oils and ointments.