Acne

By Peter Galvin, MD

The 19-year-old man in the photos presented to the dermatology clinic at First Hospital of China Medical University in Shenyang, China. He had a history of mild acne but over a 10-day period, he had rapidly worsening acne, along with fever, muscle aches, and knee pain. His temperature was elevated as well. On examination diffuse papulonodular and pustular lesions with areas of overlying crusting were noted on his forehead, nose, cheeks, and chin (Panels A and B). There were similar lesions on his neck, shoulders, chest, back, and thighs. Laboratory studies were significant for an elevated white blood cell count and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Both ESR and CRP are markers for inflammation. Skin culture grew only Cutibacterium acnes bacteria. A diagnosis of acne fulminans (AF) was made.

AF is a very rare condition. Worldwide, there have only been about 100 cases ever reported. It is a systemic inflammatory condition with fever, myalgias (muscle aches), and arthralgias (joint pain), as was seen in this case. It can also cause swelling of the lymph nodes in the neck and loss of appetite. AF has genetic factors and is associated with isotretinoin (Accutane) use. In many cases, it is preceded by acne conglobata (AC). AC is more common than AF. AC includes comedomes (clogged hair follicles [pores] that are either whiteheads or blackheads), nodules, and abscesses. AC is associated with elevated testosterone levels, which is why it is almost exclusively seen in men and can appear with anabolic steroid abuse. AC is associated with C acnes bacterial overgrowth on the skin, which leads to the formation of antibodies to that bacterium. It is those antibodies that cause the inflammatory response seen in AF.

The patient in this case was treated with oral glucocorticoids (prednisone), isotretinoin, and topical antibiotics. AF does not respond to oral or intravenous antibiotics. At his six-week follow-up, his symptoms had resolved, and the acne had abated (Panel C). This case was published in the “New England Journal of Medicine.”

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