eMedicine Specialties > Dermatology > Diseases of the Adnexa

Acne Fulminans: Differential Diagnoses & Workup

Author: Ryszard Zaba, MD, PhD, Director, Department of Dermatology, Professor, Department of Dermatology and Venereology, Poznan University School of Medical Sciences, Poland
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Mar 12, 2009

Differential Diagnoses

Acne Conglobata
Acne Vulgaris
Acneiform Eruptions
Pyoderma Gangrenosum

Other Problems to Be Considered

Rosacea fulminans
Proliferative granulation tissue from use of isotretinoin to treat acne conglobata
Acne conglobata: Acne fulminans should be distinguished from acne conglobata because acne fulminans may cause systemic illness, it does not respond to antibiotics, and it requires different therapy.

Workup

Laboratory Studies

  • Findings in patients with acne fulminans include the following:
    • Leukocytosis (characteristic finding)
    • Increased percentage of polymorphonuclear leukocytes
    • Anemia
    • Leukemic-type reaction
    • Elevated erythrocyte sedimentation rate
    • Circulating immune complexes
    • Proteinuria
  • Blood cultures are universally sterile.

Imaging Studies

  • Bone involvement is common.
    • Approximately 50% of patients have lytic bone lesions demonstrated on radiographs, and 70% of patients show increased uptake using technetium scintillography ("hot spots").
    • Destructive lesions resembling osteomyelitis are demonstrated on radiographs in 25% of patients.
    • Multifocal osteolytic cysts may be evident as tender bones and can be detected as hot spots by technetium scintillography.

Histologic Findings

Analysis of biopsy specimens of the bony lesions shows reactive changes only.

More on Acne Fulminans

Overview: Acne Fulminans
Differential Diagnoses & Workup: Acne Fulminans
Treatment & Medication: Acne Fulminans
Follow-up: Acne Fulminans
References
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References

  1. Burns RE, Colville JM. Acne conglobata with septicemia. Arch Dermatol. 1959;79:361-3.

  2. Windom RE, Sanford JP, Ziff M. Acne conglobata and arthritis. Arthritis Rheum. Dec 1961;4:632-5. [Medline].

  3. Iqbal M, Kolodney MS. Acne fulminans with synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome treated with infliximab. J Am Acad Dermatol. May 2005;52(5 Suppl 1):S118-20. [Medline].

  4. Wollina U, Gesina H, Koch A, Kostler E. Case reports: acne fulminans in Marfan syndrome. J Drugs Dermatol. Jul-Aug 2005;4(4):501-5. [Medline].

  5. Heydenreich G. Testosterone and anabolic steroids and acne fulminans. Arch Dermatol. Apr 1989;125(4):571-2. [Medline].

  6. Kalbarczyk K, Ciupinska M. Complications during treatment with Roaccutane, acne fulminans 2001. Dermatol Klin (Wroclaw). 2001;3 (Suppl 1):130.

  7. Palatsi R, Oikarinen A. Hormonal analysis and delayed hypersensitivity reactions in identical twins with severe acne. Acta Derm Venereol. 1979;59(2):157-60. [Medline].

  8. Placzek M, Degitz K, Schmidt H, Plewig G. Acne fulminans in late-onset congenital adrenal hyperplasia. Lancet. Aug 28 1999;354(9180):739-40. [Medline].

  9. Williamson DM, Cunliffe WJ, Gatecliff M, Scott DG. Acute ulcerative acne conglobata (acne fulminans) with erythema nodosum. Clin Exp Dermatol. Dec 1977;2(4):351-4. [Medline].

  10. Gordon PM, Farr PM, Milligan A. Acne fulminans and bone lesions may present to other specialties. Pediatr Dermatol. Nov-Dec 1997;14(6):446-8. [Medline].

  11. Allison MA, Dunn CL, Person DA. Acne fulminans treated with isotretinoin and "pulse" corticosteroids. Pediatr Dermatol. Jan-Feb 1997;14(1):39-42. [Medline].

  12. Leyden JJ. The role of isotretinoin in the treatment of acne: personal observations. J Am Acad Dermatol. Aug 1998;39(2 Pt 3):S45-9. [Medline].

  13. Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. Aug 1999;141(2):307-9. [Medline].

  14. Friedlander SF. Effective treatment of acne fulminans-associated granulation tissue with the pulsed dye laser. Pediatr Dermatol. Sep-Oct 1998;15(5):396-8. [Medline].

  15. Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Rook/Wilkinson/Ebling Textbook of Dermatology. 6th ed. Oxford, England: Blackwell Science; 1998:1967-79.

  16. Cunliffe WJ, Gollnick H. Acne fulminans. In: Cunliffe WJ, Gollnick H. Acne. Diagnosis and Management. London, England: Martin Dunitz Ltd; 2001:84-6.

  17. Jansen T, Plewig G. Acne fulminans. Int J Dermatol. Apr 1998;37(4):254-7. [Medline].

  18. Jansen T, Romiti R, Plewig G. Acute severe acne in a female patient (acne fulminans?). Br J Dermatol. Nov 1999;141(5):945-7. [Medline].

  19. Thomson KF, Cunliffe WJ. Acne fulminans 'sine fulminans'. Clin Exp Dermatol. Jun 2000;25(4):299-301. [Medline].

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Further Reading

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Keywords

acne fulminans, acute febrile ulcerative conglobata acne with polyarthritis, acute febrile ulcerative conglobata acne with leukemoid reaction, acne maligna, acute ulcerative acne conglobata

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Contributor Information and Disclosures

Author

Ryszard Zaba, MD, PhD, Director, Department of Dermatology, Professor, Department of Dermatology and Venereology, Poznan University School of Medical Sciences, Poland
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Alexa F Boer Kimball, MD, MPH, Associate Professor of Dermatology, Harvard University School of Medicine; Vice Chair, Department of Dermatology, Massachusetts General Hospital; Director of Clinical Unit for Research Trials in Skin (CURTIS), Department of Dermatology, Massachusetts General Hospital and Brigham and Women's Hospital
Alexa F Boer Kimball, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

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