By Gary M. White, MD
Acne fulminans (AF) is the explosive flare of crusted, inflammatory acne lesions in a patient with acne.
The patient experiences the explosive onset of inflammatory nodules, crust, and ulcerative lesions on the upper trunk, especially the midchest and shoulders. There is often a history of mild acne. The most commonly affected patients are tall, white teenage boys. AF may be precipitated by isotretinoin therapy, testosterone therapy, or it may develop without any obvious trigger factors. Pyogenic granuloma lesions may form in the crusts.
Initial therapy often requires prednisone 0.5-1.0 mg/kg/day for 4-6 weeks until control is achieved followed by slow tapering. Any crusting or pyogenic granuloma-like lesions may be treated with a potent class one topical steroid (e.g., clobetasol ointment). Despite appropriate therapy, most patients scar badly. See acne scars.
If the AF was precipitated by isotretinoin, the isotretinoin should be stopped and prednisone given. In such cases, the patient may be tried on isotretinoin again at a future time (low dose initially, e.g. 0.1 mg/kg/day).
If isotretinoin was not the cause, then oral isotretinoin (e.g., 0.1-0.5 mg/kg/day) may be added after 2-4 weeks of prednisone. Starting the isotretinoin too soon or at too high a dose can flare the AF. The dose should be slowly increased to 1 mg/kg/day as the AF lesions clear. A standard course of isotretinoin (e.g., with a cumulative dose of 120 mg/kg) should be given--longer if needed. The prednisone should be tapered off over 2-4 months.
Cyclosporin is an alternative to prednisone. It was successfully employed in one case at a dose of 5 mg/kg/day [JAAD Feb 2014].
Interesting sparing of the upper chest/neck.
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