Acne Fulminans
Acne fulminans is a rare and particularly severe form of acne. It begins abruptly with inflamed nodules and cysts that break down into ulcers covered by hemorrhagic crusts, mostly on the chest, back and face. What sets it apart from other forms of severe inflammatory acne is that systemic symptoms appear at the same time: fever, joint pain, bone destruction, fatigue and a marked rise in white blood cells.
The disease reflects a systemic hypersensitivity reaction to antigens from the bacterium Cutibacterium acnes:
- Type III and IV hypersensitivity: When follicles rupture, large amounts of C. acnes antigen spill into the circulation. In susceptible people, the body responds by forming circulating immune complexes, activating complement and setting off a systemic inflammatory cytokine cascade that causes sterile necrotizing vasculitis in the skin.
- Systemic cytokine storm: Surging levels of mediators such as interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF-alpha) drive the systemic features. These cytokines act on the hypothalamic temperature center to cause fever and activate osteoclasts, leading to bone resorption and sterile arthritis that typically involves the sternoclavicular and acromioclavicular joints and the large joints of the legs.
- Treatment as a trigger: In many cases, acne fulminans starts shortly after a patient begins oral isotretinoin. The drug causes a sudden collapse of sebaceous gland cells, releasing a flood of bacterial antigen and pushing the immune system into overdrive.
At Haute-Derma, our first priority in the acute phase is to calm the systemic inflammation and bring the skin necrosis under control, while avoiding any mechanical or procedural manipulation of the lesions so that the risk of secondary infection and extensive disfiguring scars is kept as low as possible.
Our Approach to Acne Fulminans at Haute-Derma
Controlling acne fulminans requires systemic medical treatment and gentle, conservative wound care working closely together:
- Systemic inflammation first, cosmetic procedures later: Ablative laser, chemical peels and manual extraction are contraindicated while lesions are ulcerated, necrotic or oozing blood.
- Carefully sequenced systemic therapy: Isotretinoin on its own is contraindicated at this stage because it can worsen the necrosis. Treatment must begin with systemic anti-inflammatory therapy to stabilize the skin before isotretinoin is reconsidered.
- Conservative, non-invasive wound care: Necrotic ulcers are cleaned with a mild antiseptic and covered with non-adherent biological dressings to support natural re-epithelialization.
Clinical Assessment and Systemic Screening
Building a clinical record for a patient with acne fulminans involves the following steps:
- Examination and assessment of systemic symptoms: We check body temperature, ask about bone and joint pain (especially around the chest and shoulders) and palpate for localized bone or joint tenderness.
- Essential laboratory tests:
- Complete blood count (CBC): Screens for neutrophilic leukocytosis and anemia.
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Gauge how active the systemic inflammation is.
- Liver function (AST, ALT) and lipid panel: Baseline values before long-term systemic medication.
- Imaging when indicated: X-rays or bone scintigraphy of painful joints help detect sterile osteolytic lesions early.
Clinical Management and Treatment at Haute-Derma
Treatment aims to switch off the systemic immune reaction, protect the basement membrane and support healing of the epidermis:
- Combined systemic therapy:
- Oral corticosteroids: The first-line choice to rapidly suppress the necrotizing inflammation and control systemic symptoms such as fever and joint pain.
- Oral isotretinoin: Started or restarted only at a very low dose once corticosteroids have fully controlled the systemic inflammation and skin necrosis. The dose is then increased gradually according to clinical response.
- Anti-TNF-alpha biologics: Considered after multidisciplinary review for severe, refractory cases that do not respond to corticosteroids plus isotretinoin.
- Conservative local wound care:
- Hydrocolloid or sterile petrolatum-impregnated dressings are applied to necrotic ulcers to protect exposed nerve endings, ease pain and promote healing while limiting contracted scars.
- Strongly exfoliating topicals such as high-strength benzoyl peroxide or salicylic acid should be avoided on eroded or ulcerated skin.
- Therapeutic light (photobiomodulation):
- Red (633 nm) and near-infrared (830 nm) LED light is used in a non-thermal mode. It stimulates mitochondrial activity and improves local microcirculation, speeding up re-epithelialization and easing swelling and pain.
