Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

Recognizing and Managing Isotretinoin-Induced Acne Fulminans without Systemic Symptoms

By M. Bryn Marsh, MPAS, PA-C

ABSTRACT
This report describes the case of a 14-year-old female patient who presented with severe nodulocystic acne on the face that started 6 to 8 weeks into treatment with isotretinoin. The patient complained of intermittent arthralgias but denied other systemic symptoms. She was diagnosed with acne fulminans without systemic symptoms induced by isotretinoin. She discontinued this medication and began a prolonged prednisone taper. As this began to mitigate the acute inflammation, isotretinoin was re-initiated and gradually up-titrated to induce long-term control of her acne. Acne fulminans has multiple clinical manifestations, thus making it difficult to distinguish at times. Management of this condition can also be challenging and requires a personalized approach. Isotretinoin-induced acne fulminans is increasing in incidence due to more widespread treatment of acne vulgaris with this medication. The prompt recognition and management of this adverse effect of isotretinoin can prevent it from progressing into fulminant disease, and diminish the number of disfiguring scars.

GRAND ROUNDS QUIZ

1. Which adverse effect may occur with concomitant treatment with isotretinoin and tetracycline antibiotics?
a.) Osteolytic bone lesions
b.) Pseudotumor cerebri
c.) Gastric ulcers
d.) Leukocytopenia

2. What medication is the mainstay for quick resolution of inflammation in acne fulminans?
a.) Oral corticosteroids
b.) Topical corticosteroids
c.) Oral antibiotics
d.) Isotretinoin

3. At what point after starting isotretinoin does isotretinoin-induced acne fulminans generally present?
a.) Immediately
b.) Within the first 2 weeks
c.) Between months one and two
d.) Between months three and four

CLINICAL VIGNETTE
Initiating isotretinoin. A 14-year-old female patient presented to the dermatology clinic with a history of mild to moderate acne, which failed to adequately improve with use of dapsone gel, adapalene/benzoyl peroxide gel, 0.05% tretinoin cream, and one year of intermittent daily oral 55 mg extended-release minocycline. The acne consisted of comedones and small inflammatory papules predominantly on the forehead. The patient’s brother and mother had both been treated with isotretinoin in the past with no adverse events, and her father had a history of severe cystic acne, not treated with isotretinoin. Due to the lack of improvement on traditional treatments and the patient’s strong family history of acne, the decision was made to start the patient on isotretinoin.

At baseline, the patient had mild, intermittent headaches and a slightly elevated alanine aminotransferase (ALT), which returned to normal after two months on isotretinoin. She weighed 51 kg and was started on 0.7 mg/kg/day of isotretinoin. After the first month of treatment, her acne was stable, and her lab values were unremarkable, so she was increased to a dose of 1 mg/kg/day. Two months after starting isotretinoin, she complained of worsening acne that was now spreading to the lower face and back, as well as arthralgias. At this point, her dose was decreased to 0.8 mg/kg/day, and she was advised to take ibuprofen for the joint pain. She was reassured that it could take several months for the acne to improve while taking isotretinoin.

Concern for acne fulminans begins. After three months on isotretinoin, the patient presented with continued worsening of her acne. Her exam showed multiple inflammatory papules and large nodules on the cheeks, with less involvement on the forehead. She had a few inflammatory papules on the upper back as well. The patient was still complaining of significant joint pain in her knees with exercise but denied any other systemic symptoms. It was decided to decrease her isotretinoin further (0.5 mg/kg/day) in addition to initiating a two-week prednisone taper (starting at 0.5 mg/kg/day).

Two weeks later, the patient’s acne had not improved. Her exam showed clustering of inflammatory papules and large nodules, some of which were now eroded with hemorrhagic crusts, on the bilateral cheeks. Few inflammatory papules were noted on the forehead, chin, and upper back. The patient also described serous exudate coming from her acne lesions. Monthly lipid panels and liver function tests were unremarkable other than a mildly elevated triglyceride (108) and alkaline phosphatase level (173) after month 3 of treatment. The patient was diagnosed with isotretinoin-induced acne fulminans without systemic symptoms (IIAF-WOSS).

Prednisone (1 mg/kg/day) was immediately initiated, and isotretinoin was temporarily discontinued. Additionally, doxycycline 100 mg twice daily was started as an adjunct treatment and several inflammatory nodules were successfully treated with 2.5 mg/cc of intralesional Kenalog. Prednisone was subsequently tapered slowly over the next six weeks as the patient’s inflammation decreased, hemorrhagic crusting diminished, and arthralgias resolved.

As the acne began to improve, re-starting low dose-isotretinoin was discussed with the patient and her mother several times. The patient’s mother continually declined, for fear of this worsening the patient’s acne again. The patient sought out a second opinion from a pediatric dermatologist at the Children’s Hospital who also suggested re-starting low dose isotretinoin. She agreed to this plan.

Restarting isotretinoin. Six weeks after discontinuing isotretinoin and starting a slow prednisone taper, the patient was re-started on 0.4 mg/kg/day of isotretinoin in conjunction with increasing her prednisone back up to 0.4 mg/kg/day (she had been tapered down to 0.2 mg/kg/day). She also discontinued doxycycline 48 hours prior to initiating isotretinoin. The dose of isotretinoin was slowly increased as the oral prednisone was gradually tapered over a seven-week time period. She continued to improve slowly, a few persistent nodules resolved with intralesional Kenalog, and she showed no signs of relapse throughout treatment. She reached an  isotretinoin dose of  0.7 mg/kg by month 6 and continued on the medication for a total of 12 months, at which point she reached a cumulative dose of 193 mg/kg and her acne had completely cleared. She was left with significant scarring on her forehead, bilateral cheeks, and upper back (Figure 1).

DISCUSSION
History of acne fulminans. The disease process consistent with acne fulminans (AF) was first described in 1959 under the name acne conglobata with septicemia; in 1975, it was re-named acne fulminans.1Schram A., Rosenbach M. Acne fulminans. In: Zeichner J.A. Acneiform Eruptions in Dermatology: A Differential Diagnosis. New York, NY: Springer; 2014:117-123. This new designation better describes the sudden onset of this severe condition and differentiates it from acne conglobata, which takes on a distinct disease course typified by polyporous comedones and noninflammatory cysts.2Goldschmidt H, Leyden JJ, Stein KH. Acne fulminans: investigation of acute febrile ulcerative acne. Arch Dermatol. 1977;(113):444-449.

AF is a rare disease, with around 200 cases published since first described in the literature.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 It is most common in male adolescents and was originally thought to be a disease of teenage boys exclusively.1Schram A., Rosenbach M. Acne fulminans. In: Zeichner J.A. Acneiform Eruptions in Dermatology: A Differential Diagnosis. New York, NY: Springer; 2014:117-123. 2Goldschmidt H, Leyden JJ, Stein KH. Acne fulminans: investigation of acute febrile ulcerative acne. Arch Dermatol. 1977;(113):444-449. However, there have since been several cases reported in the literature of female patients with this condition.4Karvonen SL. Acne fulminans: report of clinical findings and treatment of twenty-four patients. J Am Acad Dermatol. 1993;(28):572-579. 5Jensen T, Romiti R, Plewig G. Acute severe acne in a female patient (acne fulminans?). Br J Dermatol. 1999;(141):945-947. 6Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999;(141):307-309. 7Alakeel A, Ferneiny M, Auffret N, Bodemer C. Acne fulminans: case series and review of the literature. Pediatr Dermatol. 2016;33(6):e388-e392. doi 10.1111/pde.12983. Epub October 4, 2016. 8Thomsen KF, Cunliffe WJ. Acne fulminans ‘sine fulminans’. Clin Exp Dermatol. 2000; (25):299-301.

Clinical features and classifications. AF is the most severe variant of acne. It demonstrates abrupt onset of very inflammatory, tender, nodular, and ulcerative acne lesions involving the face, neck, and, most commonly, the upper trunk. Many patients who develop this condition have a history of only mild to moderate acne in the year preceding diagnosis.1Schram A., Rosenbach M. Acne fulminans. In: Zeichner J.A. Acneiform Eruptions in Dermatology: A Differential Diagnosis. New York, NY: Springer; 2014:117-123.

AF occurs on a spectrum of severity; in its most severe form, AF moves beyond the skin to include systemic symptoms (e.g., fever, malaise, arthralgias, and myalgias), laboratory abnormalities (e.g., leukocytosis, anemia, and increased sedimentation rate), and can even require hospitalization.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117,9Zaba R, Schwartz RA, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2011;(25):501-507.,10Neely GM, Hein MS. Acne fulminans: a case report. S D Med. 2006 Sep;59(9):387-9. It has been proposed to call this AF with systemic symptoms (AF-SS).3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 When AF is limited to the skin with no systemic manifestations, it is called AF without systemic symptoms (AF-WOSS).3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 This has also previously been named “acne fulminans sine fulminans” 8Thomsen KF, Cunliffe WJ. Acne fulminans ‘sine fulminans’. Clin Exp Dermatol. 2000; (25):299-301.,11Grando LR, Leite OG, Cestari TF. Pseudo-acne fulminans associated with oral isotretinoin. An Bras Dermatol. 2014;89(4):657-659. doi:10.1590/abd1806-4841.20143024. or “pseudo-acne fulminans.”11Grando LR, Leite OG, Cestari TF. Pseudo-acne fulminans associated with oral isotretinoin. An Bras Dermatol. 2014;89(4):657-659. doi:10.1590/abd1806-4841.20143024.

Isotretinoin is a known trigger of AF, and this phenomenon is increasing in incidence due to more widespread treatment of acne vulgaris with this medication.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 It is generally thought that a higher isotretinoin initiation dose increases the risk of developing AF and flaring typically occurs 1 to 2 months after starting the medication.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117,4Karvonen SL. Acne fulminans: report of clinical findings and treatment of twenty-four patients. J Am Acad Dermatol. 1993;(28):572-579. AF induced by isotretinoin has been further designated into two categories. When the patient exhibits systemic involvement, the condition is called isotretinoin-induced acne fulminans with systemic symptoms (IIAF-SS).3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 When no systemic symptoms are involved, this condition is called isotretinoin-induced acne fulminans without systemic symptoms (IIAF-WOSS).3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117

AF, whether induced by isotretinoin or not, is generally easily identified because of its distinct skin and systemic features. Identification becomes more of a challenge when there are no systemic symptoms.

Pathogenesis. The pathogenesis of this disease is unclear. Proposed theories include infectious, hormonal, genetic, and immunologic causes. Infectious etiology is unlikely, due to the observation that bacterial cultures yield no pathological organisms and antibiotics have been ineffective as monotherapy.2Goldschmidt H, Leyden JJ, Stein KH. Acne fulminans: investigation of acute febrile ulcerative acne. Arch Dermatol. 1977;(113):444-449.4Karvonen SL. Acne fulminans: report of clinical findings and treatment of twenty-four patients. J Am Acad Dermatol. 1993;(28):572-579.,5Jensen T, Romiti R, Plewig G. Acute severe acne in a female patient (acne fulminans?). Br J Dermatol. 1999;(141):945-947. 6Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999;(141):307-309. An increased testosterone level was also initially thought to play a role in development of AF since this disease is most commonly seen in male adolescents.9Zaba R, Schwartz RA, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2011;(25):501-507. However, subsequent cases of female patients with this condition, including those with normal blood testosterone levels, have been reported.5 Genetics do appear to play a role in development of AF as demonstrated by reports of simultaneous development of AF in identical twins,12Darley CR, Currey HL, Baker H. Acne fulminans with arthritis in identical twins
treated with isotretinoin. J R Soc Med. 1984;(77):328-330.
as well as siblings with identical human leukocyte antigen (HLA) phenotypes developing AF at the same age.13Wong SS, Pritchard MH, Holt PJ. Familial acne fulminans. Clin Exp Dermatol. 1992;(17):351-353.

Another theory states that AF occurs as a result of an immunologically mediated hypersensitivity reaction to Cutibacterium acnes (formerly Propionibacterium acnes) antigens.1Schram A., Rosenbach M. Acne fulminans. In: Zeichner J.A. Acneiform Eruptions in Dermatology: A Differential Diagnosis. New York, NY: Springer; 2014:117-123. It has been postulated that isotretinoin leads to fragility of the pilosebaceous duct epithelium, thus leading to massive release of C. acnes antigens early in the treatment course; immune system contact with this organism may then cause a type III and/or type IV hypersensitivity reaction in those genetically susceptible.9Zaba R, Schwartz RA, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2011;(25):501-507.,14Karvonen SL, Räsänen L, Cunliffe WJ, Holland KT, Karvonen J, Reunala T. Delayed hypersensitivity to Propionibacterium acnes in patients with severe nodular acne and acne fulminans. Dermatology. 1994;189(4):344-349. doi:10.1159/000246876. It has also been proven that isotretinoin causes apoptosis of sebocytes in the skin.15Nelson AM, Zhao W, Gilliland KL, Zaenglein AL, Liu W, Thiboutot DM. Temporal changes in gene expression in the skin of patients treated with isotretinoin provide insight into its mechanism of action. Dermatoendocrinol 2009;1(3):177-187. doi:10.4161/derm.1.3.8258. Another theory states that large numbers of cytokines found in these sebocytes are subsequently released into the skin, causing exaggerated inflammation.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117,16Perkins W, Crocket KV, Hodgins MB, Mackie RM, Lackie JM. The effect of treatment with 13-cis-retinoid acid on the metabolic burst of peripheral blood neutrophils from patients with acne. Br J Dermatol. 1991;(124):429-432.

Treatment options. Management of isotretinoin-induced acne fulminans can be difficult due to its poor response to traditional acne treatment.7Alakeel A, Ferneiny M, Auffret N, Bodemer C. Acne fulminans: case series and review of the literature. Pediatr Dermatol. 2016;33(6):e388-e392. doi 10.1111/pde.12983. Epub October 4, 2016. Because of this, each patient requires a personalized treatment plan based on their particular circumstances and response to therapy. Oral corticosteroids plus isotretinoin are considered the mainstay of treatment for all forms of acne fulminans.1Schram A., Rosenbach M. Acne fulminans. In: Zeichner J.A. Acneiform Eruptions
in Dermatology: A Differential Diagnosis. New York, NY: Springer; 2014:117-123.
,3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117,5Jensen T, Romiti R, Plewig G. Acute severe acne in a female patient (acne fulminans?). Br J Dermatol. 1999;(141):945-947.,6Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999;(141):307-309.,8Thomsen KF, Cunliffe WJ. Acne fulminans ‘sine fulminans’. Clin Exp Dermatol.
2000; (25):299-301.
,9Zaba R, Schwartz RA, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2011;(25):501-507. This regimen leads to long-term control of the acne.1 Oral antibiotics have also been used with varying degrees of success.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117,4Karvonen SL. Acne fulminans: report of clinical findings and treatment of twenty-four patients. J Am Acad Dermatol. 1993;(28):572-579.,6Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999;(141):307-309. In particularly resistant cases, there have been reports of treatment success with infliximab, cyclosporine, azathioprine, and dapsone.7Alakeel A, Ferneiny M, Auffret N, Bodemer C. Acne fulminans: case series and review of the literature. Pediatr Dermatol. 2016;33(6):e388-e392. doi 10.1111/pde.12983. Epub October 4, 2016.

If isotretinoin-induced acne fulminans is suspected, discontinuing isotretinoin and initiating oral corticosteroids to gain quick control of inflammation is recommended; prednisone 0.5-1.0 mg/kg/day should be given for 2 to 4 weeks and then gradually tapered over weeks to months depending on the patient’s response.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 Once control of the acute flare has been achieved, low-dose isotretinoin should be re-initiated at a dose of 0.1-0.25 mg/kg/day, overlapping with corticosteroids for at least four weeks. The isotretinoin dose should then be gradually increased to 1.0 mg/kg/day and continued until a minimum cumulative dose of 120 mg/kg is reached and clinical clearance is observed.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117,8Thomsen KF, Cunliffe WJ. Acne fulminans ‘sine fulminans’. Clin Exp Dermatol. 2000; (25):299-301.,9Zaba R, Schwartz RA, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2011;(25):501-507.,10Neely GM, Hein MS. Acne fulminans: a case report. S D Med. 2006 Sep;59(9):387-9.,17Zaba R, Schwartz RA: Acne Fulminans. eMedicine from WebMD. Updated: Feb 08, 2019. Accessed October 30, 2020. https://emedicine.medscape.com/article/1072815-overview.

Oral antibiotics have proven to be unhelpful as monotherapy.1Schram A., Rosenbach M. Acne fulminans. In: Zeichner J.A. Acneiform Eruptions in Dermatology: A Differential Diagnosis. New York, NY: Springer; 2014:117-123.,2Goldschmidt H, Leyden JJ, Stein KH. Acne fulminans: investigation of acute febrile ulcerative acne. Arch Dermatol. 1977;(113):444-449.,3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 6Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999;(141):307-309. However, improvement has been demonstrated when oral corticosteroids are used in conjunction with antibiotics.6Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999;(141):307-309. 18Meena M, Mittal A, Khare AK, Gupta LK. Pseudo Acne fulminans: an underrecognized entity. Indian Dermatol Online J. 2018;Nov-Dec;9(6): 462-464.
doi:10.4103/idoj.IDOJ_296_17.
This may be valuable in cases where isotretinoin needs to be avoided for any reason. It is important to refrain from prescribing oral tetracycline antibiotics in conjunction with isotretinoin due to the possible additive risk of inducing pseudotumor cerebri.11Grando LR, Leite OG, Cestari TF. Pseudo-acne fulminans associated with oral isotretinoin. An Bras Dermatol. 2014;89(4):657-659. doi:10.1590/abd1806-4841.20143024.

AF is slow to completely resolve, even with proper treatment, and often leaves disfiguring scars; therefore, prompt recognition is paramount to treatment success.

Prevention. It is recommended that patients who have severe inflammatory acne start oral corticosteroids prior to or in conjunction with isotretinoin to avoid triggering AF. The patient should be started on oral corticosteroids for 2-4 weeks before prescribing isotretinoin or concurrently with the start of isotretinoin (0.5-1.0 mg/kg/day).3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117,19Kaminsky A. Less common methods to treat acne. Dermatology. 2003;(206):68-73. doi:10.1159/000067824

Prognosis. There is a good long-term prognosis in acne fulminans. Relapse is uncommon one year after treatment with isotretinoin.4Karvonen SL. Acne fulminans: report of clinical findings and treatment of
twenty-four patients. J Am Acad Dermatol. 1993;(28):572-579.
However, significant scarring is likely to occur.

CONCLUSION
AF without systemic symptoms is not always easily recognizable, and cases induced by isotretinoin are increasing in incidence due to the widespread prescribing of isotretinoin for acne vulgaris.3Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117 This condition leads to disfiguring scars, as well as significant patient distress. Those practicing in dermatology should be able to distinguish these patients early to improve long-term outcomes and patient satisfaction.

JDPA Grand Rounds Quiz Answer Key: 1. B; 2. A; 3. C

M. Bryn Marsh, MPAS, PA-C, is from Hill Center for Dermatology in Golden, Colorado.

Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.

References

  • 1
    Schram A., Rosenbach M. Acne fulminans. In: Zeichner J.A. Acneiform Eruptions in Dermatology: A Differential Diagnosis. New York, NY: Springer; 2014:117-123.
  • 2
    Goldschmidt H, Leyden JJ, Stein KH. Acne fulminans: investigation of acute febrile ulcerative acne. Arch Dermatol. 1977;(113):444-449.
  • 3
    Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne vulgaris and its variants. J Am Acad Dermatol. 2017;77(1):109-117
  • 4
    Karvonen SL. Acne fulminans: report of clinical findings and treatment of
    twenty-four patients. J Am Acad Dermatol. 1993;(28):572-579.
  • 5
    Jensen T, Romiti R, Plewig G. Acute severe acne in a female patient (acne fulminans?). Br J Dermatol. 1999;(141):945-947.
  • 6
    Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol. 1999;(141):307-309.
  • 7
    Alakeel A, Ferneiny M, Auffret N, Bodemer C. Acne fulminans: case series and review of the literature. Pediatr Dermatol. 2016;33(6):e388-e392. doi 10.1111/pde.12983. Epub October 4, 2016.
  • 8
    Thomsen KF, Cunliffe WJ. Acne fulminans ‘sine fulminans’. Clin Exp Dermatol. 2000; (25):299-301.
  • 9
    Zaba R, Schwartz RA, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2011;(25):501-507.
  • 10
    Neely GM, Hein MS. Acne fulminans: a case report. S D Med. 2006 Sep;59(9):387-9.
  • 11
    Grando LR, Leite OG, Cestari TF. Pseudo-acne fulminans associated with oral isotretinoin. An Bras Dermatol. 2014;89(4):657-659. doi:10.1590/abd1806-4841.20143024.
  • 12
    Darley CR, Currey HL, Baker H. Acne fulminans with arthritis in identical twins
    treated with isotretinoin. J R Soc Med. 1984;(77):328-330.
  • 13
    Wong SS, Pritchard MH, Holt PJ. Familial acne fulminans. Clin Exp Dermatol. 1992;(17):351-353.
  • 14
    Karvonen SL, Räsänen L, Cunliffe WJ, Holland KT, Karvonen J, Reunala T. Delayed hypersensitivity to Propionibacterium acnes in patients with severe nodular acne and acne fulminans. Dermatology. 1994;189(4):344-349. doi:10.1159/000246876.
  • 15
    Nelson AM, Zhao W, Gilliland KL, Zaenglein AL, Liu W, Thiboutot DM. Temporal changes in gene expression in the skin of patients treated with isotretinoin provide insight into its mechanism of action. Dermatoendocrinol 2009;1(3):177-187. doi:10.4161/derm.1.3.8258.
  • 16
    Perkins W, Crocket KV, Hodgins MB, Mackie RM, Lackie JM. The effect of treatment with 13-cis-retinoid acid on the metabolic burst of peripheral blood neutrophils from patients with acne. Br J Dermatol. 1991;(124):429-432.
  • 17
    Zaba R, Schwartz RA: Acne Fulminans. eMedicine from WebMD. Updated: Feb 08, 2019. Accessed October 30, 2020. https://emedicine.medscape.com/article/1072815-overview.
  • 18
    Meena M, Mittal A, Khare AK, Gupta LK. Pseudo Acne fulminans: an underrecognized entity. Indian Dermatol Online J. 2018;Nov-Dec;9(6): 462-464.
    doi:10.4103/idoj.IDOJ_296_17.
  • 19
    Kaminsky A. Less common methods to treat acne. Dermatology. 2003;(206):68-73. doi:10.1159/000067824

Like this article?

Share on facebook
Share on Facebook
Share on twitter
Share on Twitter
Share on linkedin
Share on Linkdin