What are the other Names for this Condition? (Also known as/Synonyms)

• Acne Maligna
• Acute Febrile Ulcerative Acne
• Malignant Acne

What is Acne Fulminans? (Definition/Background Information)

• Acne is a common skin condition that causes inflamed red spots/lesions to appear on the face, neck, shoulders, and other regions. The condition occurs when the sebaceous glands combined with the tiny hairs (purely sebaceous glands) become clogged with dead cells and non-flowing oil
• Acne Fulminans (AF) is a severe form of acne wherein the individual has not only skin symptoms but also systemic symptoms. It can be described as the deterioration of acne with fever and joint aches. AF is an extremely rare condition
• Acne Fulminans is also known as Malignant Acne and is most frequently observed in young adult and adolescent males. It may result as a side effect of acne conglobata
• The cause of the condition is unknown, but it may be influenced by factors such as the use and abuse of anabolic steroids (typically for sports), a paradoxical flare in response to isotretinoin treatment of acne, and a positive family history of Acne Fulminans
• In addition to skin lesions that can lead to severe scarring and disfigurement, the systemic signs and symptoms may include joint inflammation and pain, weight loss, muscle atrophy, and enlarged liver and spleen
• Acne Fulminans may be treated with antibiotics, a course of oral corticosteroids and isotretinoin, laser therapy, and immunotherapy; symptomatic treatment may be provided for the systemic presentations. The prognosis of the condition depends upon several factors, including on the severity of the signs and symptoms

Tropical Acne is reported, almost exclusively in young males, in hot-humid environments for prolonged stays. Reports were first recorded during tropical warfare in the Second World War. The signs and symptoms are similar to Acne Fulminans.

Who gets Acne Fulminans? (Age and Sex Distribution)

• Acne Fulminans is an extremely uncommon condition that is almost only seen to develop in adolescent and young adult males between the age of 15-25 years
• Rarely, females may be affected
• There is no racial or ethnic predilection, and the condition may be seen worldwide

What are the Risk Factors for Acne Fulminans? (Predisposing Factors)

The following are the risk factors for Acne Fulminans:

• Untreated or inadequately treated acne conglobata
• Puberty with increased androgens in the body
• Use or abuse of performance-enhancing anabolic steroids
• Taking supplemental testosterone or other androgens
• Use of oral isotretinoin medication
• The condition can run in families, and hence, those with a positive medical history may develop Acne Fulminans

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Acne Fulminans? (Etiology)

The cause of Acne Fulminans is unknown.

• It occurs due to a sudden worsening of existing acne conglobata due to various factors; particularly when it is not treated successfully
• It is considered an exaggerated immune response of the body to acne caused by the bacterial pathogen Propionibacteria acnes. It may result due to a hypersensitivity reaction of some of the antigens of the bacterium
• A few researchers believe that it may be a reaction to certain hormones, medications, or drugs

The SAPHO syndrome has many of the elements of Acne Fulminans or may represent a subset of Acne Fulminans.

What are the Signs and Symptoms of Acne Fulminans?

The signs and symptoms of Acne Fulminans, a severe form of acne with a sudden onset, are as follows:

Skin symptoms may include:

• Highly inflammatory and painful skin lesions or nodules on the trunk (chest and back)
• The skin lesions can bleed and ulcerate
• Formation of skin ulcers with the discharge of pus
• Scarring of the skin

Systemic symptoms may include:

• Fever and malaise (general feeling of illness)
• Pain and inflammation in the ankle, knee, and shoulder joints
• Swelling of lymph nodes
• Loss of appetite that may result in weight loss
• Muscular atrophy and weakness
• Enlarged spleen (splenomegaly)
• Enlarged liver (hepatomegaly)
• Lytic lesions of the bone (non-infectious osteomyelitis)

How is Acne Fulminans Diagnosed?

The diagnosis of Acne Fulminans may involve the following tests and procedures:

• Thorough physical examination and medical history evaluation
• Examination of the skin condition by a dermatologist
• Blood tests that include complete blood count (CBC) test, erythrocyte sedimentation rate (ESR) test, and C-reactive protein (CRP) test
• Blood culture
• Radiological imaging studies of affected areas to rule-out underlying bone infections or non-infectious bone changes
• Skin biopsy: A biopsy is performed and sent to a laboratory for a pathological examination. The pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed), and microscope findings, the pathologist arrives at a definitive diagnosis

A differential diagnosis may be undertaken to rule-out the following skin conditions:

• Acne conglobata
• Acne vulgaris
• Other acneiform eruptions
• Pyoderma gangrenosum
• Rosacea fulminans
• SAPHO syndrome: Synovitis, acne, pustulosis,hyperostosis, and osteitis syndrome

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Acne Fulminans?

Some of the complications of Acne Fulminans include:

• Severe psychological stress
• Cosmetic disfigurement requiring extensive surgical (restoration) treatment
• Inflammation of underlying bone (aseptic osteomyelitis)
• Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome (or SAPHO syndrome)

How is Acne Fulminans Treated?

Treatment measures for Acne Fulminans may include the following:

• Oral antibiotics, which are not regularly as successful as in other forms of acne
• Administration of pain medication
• Systemic corticosteroid therapy
• Institution of low-dose, long-term isotretinoin after the corticosteroids have lessened inflammation
• Immunomodulation therapy: Use of medications that alter the immune system, such as cyclosporin, dapsone, infliximab, or etanercept
• It is important to always discuss the advisability of the use of any medication with one’s healthcare provider before undertaking a treatment course
• Cosmetic procedures, such as chemical peeling, minor skin surgery (punch excision), and microdermabrasion, may be used for scarring after resolution of the active inflammation
• Pulsed dye laser therapy
• Other cosmetic restorative surgery
• Undertaking treatment of any underlying condition/disorder

Note: The use of topical gels and creams is not helpful in treating Acne Fulminans.

How can Acne Fulminans be Prevented?

Acne Fulminans is a very rare condition that may not be preventable in some cases. In some other cases, the following measures may be considered:

• Undertaking appropriate early treatment of acne conglobata, which can help prevent Acne Fulminans
• Using performance-enhancing anabolic steroids under strict medical supervision while considering their side effects
• Assessing the side effects of certain medications or hormones before taking them

What is the Prognosis of Acne Fulminans? (Outcomes/Resolutions)

Acne Fulminans is a severe form of acne. The prognosis of the condition depends upon the severity of the signs and symptoms, the response to treatment, and the severity of the underlying condition.

Additional and Relevant Useful Information for Acne Fulminans:

• There is no evidence to prove that oily foods and chocolate-based products influence Acne Fulminans
• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition
• The presence of dirt on the body is not a causative factor for Acne Fulminans; but it helps to be clean and hygienic