This Expert Shares Problem-Solving Insights About a Challenging Acne Case

A 15-year-old male patient presented with ulcerated, erosive and nodular lesions on his face, back and chest. He’d been diagnosed with acne 1 year before and was originally treated by another physician with topical therapies and systemic antibiotics. Because his acne continued to worsen, he was started on isotretinoin 60 mg/day (Accutane). Two weeks after starting this treatment, he’d developed severe inflammation on his face, back and chest along with fever, myalgias and joint pain. He had been hospitalized for fever and leukocytosis, and treated with clarithromycin 250 mg b.i.d. (Biaxin), prednisone 40 mg/day. His fever and malaise improved on 40 mg/day of prednisone, but returned when the dose was reduced to 30 mg/day after a few days. When he first presented at our practice, his medications included prednisone 30 mg/day, clarithromycin 250 mg b.i.d. and ibuprofen 600 q.i.d. During examination, I found he had severe nodular acne, with erosions over the face, back and chest (see photo). He was afebrile, and his weight was 125 lbs. Diagnosis and Treatment Diagnosis was acne fulminans. For his course of treatment, I increased the prednisone to 60 mg/day for 2 weeks and then 40 mg/day. After 1 week, isotretinoin was restarted at 20 mg/day, and Oscal-D (vitamin D and calcium) was added to minimize prednisone-induced bone loss. Over the next 2 months, prednisone was decreased slowly and isotretinoin was gradually increased to 80 mg/day. Routine laboratory tests were monitored and remained normal. His inflammation improved slowly, as did his constitutional symptoms. After 3 months of treatment, at a dose of 5 mg/day of prednisone, his face pain increased and some nodules began to enlarge. Prednisone was then increased to 20 mg every other day, and isotretinoin was increased to 120 mg/day. Over the next 2 months, prednisone was gradually tapered and stopped, and isotretinoin was held at a dose of 120 mg/day. When a decision was made to stop all treatment, his inflammation was significantly improved, and he began to inquire about cosmetic correction of the scars. Discussion Acne fulminans is a severe form of nodular acne that results in open suppurative erosions, fever, leukocytosis, myalgias, arthralgias and, occasionally, osteolytic lesions. It’s seen mostly in teenage boys. Although isotretinoin is part of the treatment of acne fulminans, there are numerous reports of isolated cases of acne fulminans triggered by isotretinoin. Treatment is difficult and usually requires aggressive modalities. Prednisone 40 mg to 60 mg/day is usually required as initial therapy and can be tapered slowly over months. Isotretinoin is recommended after inflammation partially improves. Starting dosages of less than 0.5 mg/kg/day, gradually increased to approximately 1 mg/kg/day are best, with maintenance until clear. In most acne patients treated with isotretinoin, a total accumulative dose is usually around 120 mg/kg. Our patient received a total accumulative dose of approximately 200 mg/kg before he was clear enough to stop the drug. Cosmetic treatment of scars after isotretinoin is not recommended for at least 1 year. Before that time, that risk of scarring complications is much higher.