Severe inflammatory acne

Severe forms of acne

Severe forms of acne are uncommon but can cause substantial problems, alter the appearance of facial skin and affect emotional well-being. The following conditions can cause severe lesions.

Acne conglobata

This is among the most severe forms of common acne and is more frequent in men. It is a form of nodulocystic acne with interconnected abscesses and sinus tracts. It can cause both thick, raised hypertrophic scars and depressed atrophic scars. Large comedones, or macrocomedones, and pus-filled cysts with an unpleasant odor may occur.

Severe scarring can alter the skin’s appearance. Sites include the face, chest, back, buttocks, upper arms and thighs. It commonly begins between ages 18 and 30 and may flare for years. It can be difficult to treat. A dermatologist may consider oral isotretinoin according to its indications and precautions.

Acne fulminans

This is described as rapidly developing severe acne related to acne conglobata, usually in young men. Severe nodulocystic lesions often break down into ulcers and can cause extensive scarring. Characteristic accompanying symptoms include fever and joint pain, particularly in the hips and knees.

It often responds poorly to antibiotics. A specialist may consider oral isotretinoin and corticosteroids, with a carefully planned sequence of treatment and close monitoring. Other difficult-to-treat severe acne may have occurred previously.

Gram-negative folliculitis

This is a gram-negative bacterial infection with pustules and cysts. It may develop as a complication of prolonged antibiotic treatment for acne vulgaris. It is uncommon, and it is not established whether it is more frequent in men or women. Oral isotretinoin is described as a treatment to which many cases respond.

Pyoderma faciale or rosacea fulminans

This form typically concerns women aged 20–40. It involves large, painful nodules, pustules and wounds that may scar. It develops rapidly and may affect someone without a previous history of acne. It is limited to the face and is not associated with oily skin. The course is usually described as shorter than a year, although symptoms may worsen quickly.

Vasculitic acne

This is an uncommon, severe pattern with rapidly developing inflammatory lesions and ulcers. It may progress over two to three days. Immune abnormalities and vasculitis can occur together.

Specialist assessment is required. Medicines that may be considered according to the diagnosis include antibiotics, corticosteroids such as prednisolone, and immunosuppressants. These medicines should not be started without medical supervision.

Complications

Psychological effects need attention, particularly in adolescents. Renal amyloidosis has been reported. Scars may remain throughout life and can have both physical and psychological effects.

Referral and urgent assessment

1. If acne fulminans is suspected, particularly with rapidly developing severe inflammatory acne and fever or joint pain, seek urgent assessment that day. Gram-negative folliculitis needs medical assessment to confirm the diagnosis and plan treatment.
2. Severe acne with pain, deep lesions or nodulocystic acne, or acne requiring oral treatment, should be referred promptly.
3. Referral is also appropriate when acne is less severe but may scar, or when it responds poorly to treatment.