Successful treatment of acne fulminans with isotretinoin |
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Successful treatment of acne fulminans with isotretinoin

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Acne fulminans (AF), is an unusual and severe condition categorized by the unexpected onset of nodular and ulcerative acne lesions associated with systemic symptoms. It has been recognized a subset of patients with an unexpected deteriorating of acne, but without the strong presence of systemic involvement. AF, also known as acute febrile ulcerative acne, acne maligna, and acute febrile ulcerative conglobate acne with polyarthralgia, is a serious variant of acne characterized by an abrupt onset of painful, inflammatory, ulcerative lesions covered with hemorrhagic crusts, which is accompanied by severe acne scarring. The lesions often appear on the upper chest and back.

Systemic constitutional symptoms of AF include fluctuating fever, painful joints, malaise, loss of appetite, and laboratory abnormalities.  The face is usually less severely involved than the trunk. It needs to be treated immediately to avoid severe medical problems, such as permanent disfiguring scars. 

Here we reported a case with AF symptoms to highlight the need for early diagnosis and treatment of AF.

Case 

A 25-year-old boy came with a necrotizing bilateral facial wound on the jaw. He abruptly developed severe worsening of the acne lesions on the face and upper back, and nodular and ulcerated lesions appeared. Associated with the appearance of cutaneous lesions, he also reported fever, chills, arthralgia, and myalgia. On physical examination, he presented with pustules, nodules, and crusts on the face. 

A biopsy specimen from the facial ulcer showed hyperkeratosis, acanthosis associated with follicular ostium destruction, and neutrophil infiltrations, which confirmed the diagnosis of AF. Treatment started with broad-spectrum systemic antibiotics in conjunction with 1 mg/kg/day oral prednisolone.

Primary control of the lesions was obtained over the course of 4 weeks with this therapeutic regimen, with noticeable decrease in the ulcerative lesions after treatment. Prednisolone was gradually reduced over a 2-month period, and a low dose of oral isotretinoin was initiated. The patient’s acne fulminans gradually cleared within 3 months and healed, leaving a cicatricial scar on both lateral jaws.

Conclusion

AF should be suspected in patients presenting with an abrupt onset of a painful necrotizing facial wound of unknown etiology. In these settings antimicrobial agents combined with oral prednisone are an effective treatment for stabilizing clinical and laboratory parameters and preventing diseases progression. Thus, clinicians should consider AF as a differential diagnosis for facial wounds as early diagnosis and treatment can reduce the associated morbidity.

Suggested Reading

  1. D. C. Seukeran and W. J. Cunliffe, “The treatment of acne fulminans: a review of 25 cases,” British Journal of Dermatology, vol. 141, no. 2, pp. 307–309, 1999.
  2. P. Giavedoni, J. M. Mascaró-Galy, P. Aguilera, and T. Estrach-Panella, “Acne fulminans successfully treated with cyclosporine and isotretinoin,” Journal of the American Academy of Dermatology, vol. 70, no. 2, pp. e38–e39, 2014.
  3. R. Zaba, R. A. Schwartz, S. Jarmuda, M. Czarnecka-Operacz, and W. Silny, “Acne fulminans: explosive systemic form of acne,” Journal of the European Academy of Dermatology and Venereology, vol. 25, no. 5, pp. 501–507, 2011.
  4. E. Rodríguez-Lomba, I. Molina-López, I. Monteagudo-Sáez, R. Suárez-Fernández, and M. Campos-Domínguez, “A case of acne fulminans with sacroiliitis successfully treated with methotrexate and isotretinoin,” Dermatologic Therapy, vol. 29, no. 6, pp. 476–478, 2016.
  5. L. R. Grando, O. G. Leite, and T. F. Cestari, “Pseudo-acne fulminans associated with oral isotretinoin,” Anais Brasileiros de Dermatologia, vol. 89, no. 4, pp. 657–659, 2014.
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