AcneNet This Month
1999 Special Feature: Severe Acne

From time to time, AcneNet This Month will present a Special Feature on a topic suggested by Web site visitors on our Tell us about yourself questionnaire. Sometimes we’ll address a frequently-suggested topic, and sometimes a topic that concerns fewer people but is of great importance. On this month’s Special Feature we’ll discuss a topic that is suggested less frequently, but is of critical interest to those who suggest it: Severe, disfiguring forms of acne that may require years of treatment and may have one or more treatment failures.

These severe forms of acne include:

• acne conglobata
• acne fulminans
• Gram-negative folliculitis
• pyoderma faciale

These severe forms of acne are not common, and some are rare, but they are great hardships to the people who experience them. Severe forms of acne should be treated by a dermatologist.

Acne conglobata is a chronic and most severe form of acne vulgaris. The outstanding features of acne conglobata are deep abscesses, inflammation, severe damage to the skin, and scarring. Blackheads (open comedones) are usually conspicuous and widespread—often over the face, neck, truck, upper arms and buttocks. Inflammatory nodules form around multiple comedones, gradually increasing in size and then breaking down with discharge of pus. Deep ulcers may form under the nodules, leading to keloid type scars. Acne conglobata sometimes develops as a sudden intensification of papular or pustular acne, or may develop as a sudden flare-up of acne that has been under control for many years. The age of onset for acne conglobata is usually between 18 and 40 years, and the condition may remain active for 20 or more years. The cause of acne conglobata is not known. Treatment may include isotretinoin and sometimes antibiotics. Several courses of treatment may be necessary over a period of years. Although acne conglobata is often resistant to treatment, it usually can be controlled over time.

Acne fulminans is a sudden onset of highly destructive inflammation. It appears suddenly in a person with inflammatory acne, with symptoms of severe and often ulcerating acne, fever, and aching. There may be inflammation and aching of joints, especially hips and knees. A person with acne fulminans may have had unsuccessful treatment of acne conglobata. Steroids or non-steroidal anti-inflammatory medications may be given to reduce inflammation in acne fulminans. Attacks of acne fulminans may recur, and the patient may continue to have acne that requires long-term treatment with isotretinoin.

Gram-negative folliculitis is an inflammation of follicles that may occur as a complication of long-term antibiotic treatment of severe acne vulgaris. Folliculitis is an inflammation of follicles caused by infection with bacteria. In Gram-negative folliculitis, the bacteria are of a type that is often resistant to many antibiotics. Gram-negative folliculitis may appear as a sudden inflammatory flare-up of pustular or cystic acne during the course of long-term antibiotic treatment. Antibiotics that are effective against Gram-negative bacteria will probably have to be used in treatment of Gram-negative folliculitis. Treatment should be by a dermatologist or under the supervision of a dermatologist.

Pyoderma faciale affects only females, usually at ages 20 to 40 years. It appears suddenly as both deep and superficial cystic lesions of the face with interconnecting "tunnels" between cysts, reddish inflammation of the skin, and slight swelling (edema) of the skin. There are usually few if any blackheads, distinguishing this condition as quite different from acne conglobata. Regions around the cheeks, forehead, and chin are usually most severely affected. The cause of pyoderma faciale is not known. In many cases there was no acne prior to the outbreak. Some patients are so severely disfigured they may require hospitalization during the early part of treatment. Treatment may include isotretinoin and antibiotics.

Severe forms of acne often cause great embarrassment and can significantly limit a person’s social life, even interfering with opportunities for employment. Supportive family and friends can be important during treatment. It may be helpful to introduce friends and family members to information resources such as AcneNet to assist them in being more understanding.