Oral Steroids and Isotretinoin

The recommended treatment for acne fulminans is a combination of oral steroids and isotretinoin.^{[21, 22, 23]}

Oral steroids should be started and gradually reduced over 6 weeks to avoid the adverse effects of a prolonged course of systemic steroids. Some authors propose a shift with a 2-week corticosteroid treatment or 4 weeks of steroid treatment before starting isotretinoin.^[24]

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.

Suicidal ideation, a concern in seemingly healthy adolescents, should be anticipated in those with cosmetically disturbing skin disorders, such as acne fulminans. Some believe that isotretinoin may exacerbate this tendency.

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 yield a slow response in the resolution of acne and systemic symptoms. However, treatment with broad-spectrum systemic antibiotics including 300 mg clindamycin thrice daily and 750 mg levofloxacin daily in conjunction with 1 mg/kg/day oral prednisolone may be useful in some cases.^[17]The combination of oral isotretinoin and systemic steroids is better than the combination of oral isotretinoin and antibiotics. A.biological agents like as monoclonal antibody against tumor necrosis factor-alpha such as anakinra, infliximab, adalimumab may be considered as alternative therapies in selected cases for patients with acne fulminans that is unresponsive to conventional therapies^[25].

Other treatment

Friedlander reported that the pulsed dye laser is effective treatment for acne fulminans–associated granulation tissue.^[26]

Acne fulminans was successfully treated with photodynamic therapy.^[27]

The addition of diaminodiphenylsulfone was effective for treating the relapse of acne fulminans in a patient with ulcerative colitis who was successfully treated with prednisolone.^[28]

In some cases of acne fulminans, treatment with cyclosporine A and prednisolone may be also effective.^[29]

A case of acne fulminans was successfully treated with oral prednisone and dapsone.^[30]

Guidelines

Burns RE, Colville JM. Acne conglobata with septicemia. Arch Dermatol. 1959. 79:361-3.
Windom RE, Sanford JP, Ziff M. Acne conglobata and arthritis. Arthritis Rheum. 1961 Dec. 4:632-5. [QxMD MEDLINE Link].
Iqbal M, Kolodney MS. Acne fulminans with synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome treated with infliximab. J Am Acad Dermatol. 2005 May. 52(5 Suppl 1):S118-20. [QxMD MEDLINE Link].
Kraus SL, Emmert S, Schön MP, Haenssle HA. The dark side of beauty: acne fulminans induced by anabolic steroids in a male bodybuilder. Arch Dermatol. Oct 2012. 148(10):1210-2.
Lee G, Ferri-Huerta R, Greenberg KB, Somers KE. Acne fulminans in a transgender boy after an increase in testosterone dosage. JAAD Case Rep. 2022 Mar. 21:32-34. [QxMD MEDLINE Link]. [Full Text].
Wollina U, Gesina H, Koch A, Kostler E. Case reports: acne fulminans in Marfan syndrome. J Drugs Dermatol. 2005 Jul-Aug. 4(4):501-5. [QxMD MEDLINE Link].
Heydenreich G. Testosterone and anabolic steroids and acne fulminans. Arch Dermatol. 1989 Apr. 125(4):571-2. [QxMD MEDLINE Link].
Kalbarczyk K, Ciupinska M. Complications during treatment with Roaccutane, acne fulminans 2001. Dermatol Klin (Wroclaw). 2001. 3 (Suppl 1):130.
Sarifakioglu E, Onur O, Kart H, Yilmaz AE. Acute myopathy and acne fulminans triggered by isotretinoin therapy. Eur J Dermatol. Sep-Oct 2011. 21(5):794-5. [QxMD MEDLINE Link].
Palatsi R, Oikarinen A. Hormonal analysis and delayed hypersensitivity reactions in identical twins with severe acne. Acta Derm Venereol. 1979. 59(2):157-60. [QxMD MEDLINE Link].
Placzek M, Degitz K, Schmidt H, Plewig G. Acne fulminans in late-onset congenital adrenal hyperplasia. Lancet. 1999 Aug 28. 354(9180):739-40. [QxMD MEDLINE Link].
Honma M, Murakami M, Iinuma S, et al. Acne fulminans following measles infection. J Dermatol. 2009 Aug. 36(8):471-3. [QxMD MEDLINE Link].
Brănişteanu DE, Cotrutz CE, Luca MC, Molodoi DA, Stoica LE, Ianoşi SL, et al. Morphopathological stigmata in acne fulminans. Rom J Morphol Embryol. 2015. 56 (3):1185-90. [QxMD MEDLINE Link].
Ali Fakih, Jean Goens, Ivan Grozdev, Chantal Dangoisse, Bertrand Richert. Acne fulminans induced by a low dose isotretinoin: case report and review of the literature. Dermatology Online Journal. December 2020. 26(12):1-6. [Full Text].
Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne fulminans and its variants. J Am Acad Dermatol. 2017 Jul. 77 (1):109-117. [QxMD MEDLINE Link].
Zaba R, Schwartz R, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2010 Oct 3. [QxMD MEDLINE Link].
Siadat AH, Bostakian A, Abtahi-Naeini B, Shahbazi M. Successful Treatment of Facial Acne Fulminans: Antimicrobial Agents and Oral Prednisolone as Promising Regimes. Case Rep Dermatol Med. 2017. 2017:7092910. [QxMD MEDLINE Link].
Williamson DM, Cunliffe WJ, Gatecliff M, Scott DG. Acute ulcerative acne conglobata (acne fulminans) with erythema nodosum. Clin Exp Dermatol. 1977 Dec. 2(4):351-4. [QxMD MEDLINE Link].
Kim SY, Jung SK, Lee SG, Yi SM, Kim JH, Kim IH. Acne fulminans with osteolytic change in metaphysis of distal radius. Int J Dermatol. 2016 May. 55 (5):571-3. [QxMD MEDLINE Link].
Gordon PM, Farr PM, Milligan A. Acne fulminans and bone lesions may present to other specialties. Pediatr Dermatol. 1997 Nov-Dec. 14(6):446-8. [QxMD MEDLINE Link].
Allison MA, Dunn CL, Person DA. Acne fulminans treated with isotretinoin and "pulse" corticosteroids. Pediatr Dermatol. 1997 Jan-Feb. 14(1):39-42. [QxMD MEDLINE Link].
Leyden JJ. The role of isotretinoin in the treatment of acne: personal observations. J Am Acad Dermatol. 1998 Aug. 39(2 Pt 3):S45-9. [QxMD MEDLINE Link].
Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999 Aug. 141(2):307-9. [QxMD MEDLINE Link].
Massa AF, Burmeister L, Bass D, Zouboulis CC. Acne Fulminans: Treatment Experience from 26 Patients. Dermatology. 2017. 233 (2-3):136-140. [QxMD MEDLINE Link].
Claudio Marasc, Gabriella Fabbrocin, Luisa Abategiovann, Elisa Camela, Mariateresa Nocerino , Adriana Di Guida , et al. Adalimumab in the Management of Isotretinoin-Induced Acne Fulminans: Report of a Case. Clin Cosmet Investig Dermatol. Feb 2021. 155(6):115-119. [QxMD MEDLINE Link]. [Full Text].
Friedlander SF. Effective treatment of acne fulminans-associated granulation tissue with the pulsed dye laser. Pediatr Dermatol. 1998 Sep-Oct. 15(5):396-8. [QxMD MEDLINE Link].
Picone V, Potestio L, Fabbrocini G, et al. A case of acne fulminans successfully treated with photodynamic therapy. Photodermatol Photoimmunol Photomed. 2021 Dec 17. [QxMD MEDLINE Link].
Wakabayashi M, Fujimoto N, Uenishi T, Danno K, Tanaka T. A case of acne fulminans in a patient with ulcerative colitis successfully treated with prednisolone and diaminodiphenylsulfone: a literature review of acne fulminans, rosacea fulminans and neutrophilic dermatoses occurring in the setting of inflammatory bowel disease. Dermatology. 2011. 222(3):231-5. [QxMD MEDLINE Link].
Tago O, Nagai Y, Matsushima Y, Ishikawa O. A case of acne fulminans successfully treated with cyclosporin a and prednisolone. Acta Derm Venereol. May 2011. 91(3):337-8.
Lages RB, Bona SH, Silva FV, Gomes AK, Campelo V. Acne fulminans successfully treated with prednisone and dapsone. An Bras Dermatol. Jul-Aug 2012. 87(4:612-4. [QxMD MEDLINE Link].
[Guideline] Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May. 74 (5):945-973.e33. [QxMD MEDLINE Link].
[Guideline] American Academy of Dermatology. Ten Things Physicians and Patients Should Question. Choosing Wisely. Available at http://www.choosingwisely.org/societies/american-academy-of-dermatology/. August 19, 2015; Accessed: : April 30, 2016.
Federica DALL’OGLIO, Davide F. PUGLISI, Maria R. NASCA, Giuseppe MICALI. Acne fulminans. Giornale Italiano di Dermatologia e Venereologia. 2020 December. 155(6):711-8. [QxMD MEDLINE Link]. [Full Text].
Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Rook/Wilkinson/Ebling Textbook of Dermatology. 6th ed. Oxford, England: Blackwell Science; 1998. 1967-79.
Cunliffe WJ, Gollnick H. Acne fulminans. Cunliffe WJ, Gollnick H. Acne. Diagnosis and Management. London, England: Martin Dunitz Ltd; 2001. 84-6.

Media Gallery

Granulomas and crusted acne lesions in acne fulminans. Courtesy of DermNet New Zealand (http://www.dermnetnz.org/assets/Uploads/doctors/follicular/images/fulmin2.jpg).

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Author

Ryszard Zaba, MD, PhD Professor, Department of Dermatology and Venereology, Poznan University School of Medical Sciences, Poland

Ryszard Zaba, MD, PhD is a member of the following medical societies: Sigma Xi, The Scientific Research Honor Society, European Academy of Dermatology and Venereology

Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

Joshua A Zeichner, MD Assistant Professor, Director of Cosmetic and Clinical Research, Mount Sinai School of Medicine; Chief of Dermatology, Institute for Family Health at North General

Joshua A Zeichner, MD is a member of the following medical societies: American Academy of Dermatology, National Psoriasis Foundation

Disclosure: Received consulting fee from Valeant for consulting; Received grant/research funds from Medicis for other; Received consulting fee from Galderma for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Pharmaderm for consulting; Received consulting fee from Onset for consulting.

Acne Fulminans Treatment & Management

Oral Steroids and Isotretinoin

Other treatment

References

Tables

Contributor Information and Disclosures

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