eMedicine Specialties > Dermatology > Diseases of the Adnexa
Acne Fulminans: Treatment & Medication
Updated: Mar 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The recommended treatment for acne fulminans is a combination of oral steroids and isotretinoin.11,12,13
- Oral steroids should be started and gradually reduced over 6 weeks to avoid adverse effects of a prolonged course of systemic steroids.
- Isotretinoin should be started at 4 weeks, initially at 0.25 mg/kg daily and gradually increased to achieve complete clearance. Isotretinoin with a minimum total dose of 120 mg/kg is recommended. Relapses are rare. If required, a repeat course of isotretinoin (150 mg/kg) may be used.
- Some authors suggest treating patients with spontaneous development of acne fulminans with oral steroids and supplemental intralesional therapy.
- The response to broad-spectrum antibiotic treatment is poor. Oral antibiotics are responsible for a slow response in the resolution of acne and systemic symptoms. The combination of oral isotretinoin and systemic steroids is better than the combination of oral isotretinoin and antibiotics.
- Infliximab, a monoclonal antibody against tumor necrosis factor-alpha, also may be a treatment option for patients with AF that is unresponsive to conventional therapies.
Surgical Care
- Friedlander reported that the pulsed dye laser is effective treatment for acne fulminans – associated granulation tissue.14
Medication
Begin treatment with oral prednisone 1 mg/kg/d and taper over 6 weeks. By the fourth week, initiate isotretinoin at 0.25 mg/kg/d. If isotretinoin cannot be used, dapsone may be substituted for the retinoid, beginning at 50 mg/d and increasing to 100-150 mg/d.
Corticosteroids
These agents have profound and varied metabolic effects. They possess anti-inflammatory and immunosuppressive properties.
Prednisone (Delta-Cortef, Econopred)
Synthetic adrenocortical steroid with predominantly glucocorticoid properties. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Stabilizes lysosomal membranes and suppresses lymphocyte and antibody production.
Adult
0.5-1 mg/kg/d PO for 6 wk; taper as condition improves
Single morning dose is safer for long-term use, but divided doses have greater anti-inflammatory effects
Pediatric
0.14-2 mg/kg/d initial PO divided tid/qid (4-60 mg/m2/d)
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, connective tissue, and tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI tract disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur
Retinoids
Vitamin A derivatives have many roles. They encourage cellular differentiation, are antiproliferative, and serve as immunomodulators.
Isotretinoin (Accutane)
Oral agent that treats serious dermatologic conditions. Isotretinoin is the synthetic 13-cis isomer of the naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to beta-carotene. Decreases sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization.
A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.
Adult
Initial: 0.25 mg/kg/d PO; increase gradually (usually 1 mg/kg/d) for 20 wk or a total dose of 120-150 mg/kg
Pediatric
Administer as in adults
Toxicity may occur with beta carotene coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; may reduce plasma levels of carbamazepine
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May decrease night vision; inflammatory bowel disease may occur; may be associated with development of hepatitis; occasionally exaggerated healing response of acne lesions (ie, excessive granulation with crusting) may occur; patients with diabetes may experience problems controlling blood glucose levels while on isotretinoin; avoid exposure to UV light or sunlight until tolerance is achieved; discontinue if rectal bleeding, abdominal pain, or severe diarrhea occurs; mood swings or depression may occur; caution in history of depression.
Tretinoin (Avita, Retin-A, Retin-A Micro)
Structurally related to vitamin A. May be helpful for recalcitrant disease, but recurrence is common. Long-term, low-dose therapy may be suitable for selected patients.
May cause skin irritation in some patients. Also, has been linked to promotion of angiogenesis; however, has not demonstrated increased telangiectasias.
Also inhibits microcomedo formation and eliminates lesions. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.
Adult
Begin with lowest concentration of tretinoin formulation and increase as tolerated; apply hs or qod; lower frequency of application if irritation develops
Pediatric
<12 years: Not established
>12 years: Apply as in adults
Toxicity may occur with vitamin A coadministration; toxicity increased when coadministered with sulfur, benzoyl peroxide, resorcinol, or any product with strong drying effects; phototoxicity increased when coadministered with tetracyclines, fluoroquinolones, or thiazides
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with excessive sunlight exposure; burning, stinging, peeling, pruritus, or erythema has been reported at site of application; caution with eczema (may cause severe irritation); avoid contact with mucous membranes, mouth, and angles of nose
Sulfone antibiotics
These agents may inhibit bacterial growth by preventing the formation of folic acid.
Dapsone (Avlosulfon)
Bactericidal and bacteriostatic against Mycobacteria species; mechanism of action is similar to that of sulfonamides in which competitive antagonists of PABA prevent formation of folic acid, inhibiting bacterial growth. Anti-inflammatory mechanism of action may involve suppression of neutrophil function by inhibition of the halide-myeloperoxidase system. Excretion is primarily in urine; half-life is 28 h.
Adult
50-150 mg PO qd
Pediatric
Not established
May inhibit anti-inflammatory effects of clofazimine; hematologic reactions may increase with folic acid antagonists (eg, pyrimethamine); monitor for agranulocytosis during second and third mo of therapy; probenecid increases toxicity; trimethoprim with dapsone may increase toxicity of both drugs; because of increase in renal clearance, levels may decrease significantly when administered concurrently with rifampin; avoid use with zalcitabine because of increased risk of peripheral neuropathy (additive effects)
Documented hypersensitivity; G-6-PD deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Perform weekly blood counts (first mo), then WBC counts monthly (6 mo), then semiannually; discontinue if significant reduction in platelets, leukocytes, or hematopoiesis occurs; caution in patients with methemoglobin reductase deficiency, G-6-PD deficiency (patients receiving >200 mg/d), or hemoglobin M because of high risk for hemolysis and Heinz body formation; caution in patients exposed to other agents or conditions (eg, infection, diabetic ketosis) capable of producing hemolysis; peripheral neuropathy can occur (rare); phototoxicity may occur when exposed to UV light
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
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Further Reading
Keywords
acne fulminans, acute febrile ulcerative conglobata acne with polyarthritis, acute febrile ulcerative conglobata acne with leukemoid reaction, acne maligna, acute ulcerative acne conglobata
