Everything you need to know about acne fulminans

Have you suddenly developed very painful spots on your face or chest, along with fever or joint pain? You may be suffering from a rare but serious form of acne called "Acne fulminans".  

But what exactly is acne fulminans? How can it be recognised and treated? Find out more in this article.

What is acne fulminans?

Acne fulminans is a severe and serious form of inflammatory acne⁽¹⁾, fortunately it only accounts for less than 1% of acne cases. It mainly affects men (adolescents and young adults)⁽²⁾.

Unlike other forms of acne, which are chronic, acne fulminans is an acute form of the disease: it appears very quickly and causes severe, sometimes impressive lesions. While cystic acne is deep, painful, with cysts under the skin, acne fulminans mainly presents as red spots that quickly turn into open sores (ulcers) or thick scabs, sometimes with areas of dead skin.

Causes of acne fulminans

Despite scientific advances, the exact causes of acne fulminans remain partially understood⁽³⁾. However, some recent studies help to better understand the factors involved:

1. A family predisposition 
Genetic inheritance appears to play an important role in the development of acne fulminans. Studies show that the majority of patients affected had a personal and family history of severe acne^{(1 and3)}. 

2. Link to certain medical treatments
Many cases of acne fulminans are triggered by oral treatments: 

• Isotretinoin is used to treat severe acne: one study reports that this drug is associated with 60% of cases of acne fulminans⁽³⁾.
• Antibiotics: treatments such as doxycycline or lymecycline have also been linked to flare-ups of acne fulminans⁽⁴⁾

3. A hormonal imbalance: An excess of certain hormones, such as testosterone, can trigger the sudden onset of acne fulminans⁽⁵⁾.

Warning to to athletes who practise weight training: be vigilant with products containing "anabolic steroids".  These substances, used to accelerate muscle growth, can disrupt hormones and promote severe acne breakouts. 

4. No specific link to skin bacteria⁽³⁾
The bacterium Cutibacterium acnes (C. acnes), which is naturally present on the skin, is found in 80% of patients with acne fulminans.

However, the type of bacteria observed is the same as that found in acne vulgaris. This means that C. acnes cannot solely be responsible for the severe inflammation observed in acne fulminans. 

5. An excessive immune response
Scientists believe that acne fulminans may be linked to an abnormal immune system response: the skin's defence mechanisms, which are supposed to protect it, become hyperactive and cause severe inflammation, without any direct link to bacterial infection. 

Symptoms and identification of acne fulminans

Acne fulminans is characterised by numerous and often very severe inflammatory skin lesions, mainly on the face and chest, where the sebaceous glands are most active.

During your examination, the doctor will be looking to identify⁽²⁾:

• red cysts that appear suddenly, often within a few days, and cause intense pain.
• open sores (ulcerations) and scabs: cysts can open up and form sores accompanied by bleeding, which eventually become covered with thick scabs. 
• areas of necrosis: certain parts of the skin that are too damaged "die". These areas then turn brownish or dark.
• severe pain, sometimes accompanied by fever, intense fatigue and joint pain (knees, wrists, back).

Possible complications

The distinctive feature of acne fulminans is that it is accompanied by general symptoms, in other words, extra-cutaneous symptoms, whereas in other types of acne, the symptoms are limited to the skin. 

Acne fulminans can also affect the person's general condition and cause general symptoms such as⁽²⁾: 

• fever, along with the appearance of skin lesions, which is a sign of a significant inflammatory reaction.
• joint pain that may be felt in the knees, for example, or the wrists. We also talk about signs of polyarthritis, in other words, inflammation of the joints.
• extreme fatigue, as the intensity of the inflammation causes the entire body to become tired. 

Possible complications can therefore lead to an overall deterioration in general health, as well as abnormalities in biological test results. 
Acne fulminans was initially classified into two types:

1. Acne fulminans "sine fulminans", when there is no systemic presentation. 
2. Acne fulminans, when there is systemic presentation, with fever, extreme fatigue, and joint pain. 

Today, the general classification has evolved and includes four categories⁽⁶⁾:

1. Acne fulminans with systemic symptoms (AF-SS). 
2. Acne fulminans without systemic symptoms (AF-WOSS). 
3. Isotretinoin-induced acne fulminans with systemic symptoms (IIAF-SS). 
4. Isotretinoin-induced acne fulminans without systemic symptoms (IIAF-WOSS).

The different types of treatment for acne fulminans

Acne fulminans is a very severe and rare form of acne that requires rapid and specialised treatment in a hospital setting to prevent skin (scarring) and extra-cutaneous (particularly joint) complications. If you think you may be suffering from this condition, see a dermatologist straight away. 

Oral treatments

The treatment of acne fulminans primarily involves⁽⁷⁾:

1. oral cortisone, used in emergencies to reduce inflammation.
2. then the oral intake of retinoids, introduced gradually and in low doses.

These are the treatments of choice for combating inflammation on the one hand, and skin lesions and the risk of scarring on the other.

Over-the-counter creams

For a condition as severe as acne fulminans, over-the-counter creams are not suitable treatments.
However, certain dermo-cosmetic treatments may be used alongside the main treatment to soothe the skin, as directed by your doctor. For example:

• A gentle, soap-free cleanser. 
• A compensating moisturising cream to soothe irritation. 
• SPF 50+ sun protection to prevent marks and scars from worsening. 

Natural remedies

There is no natural remedy as such for treating acne fulminans. However, certain complementary solutions can accompany treatment, such as stress management techniques to better cope with symptoms. 

Prevention: how to avoid acne fulminans

The prevention of acne fulminans relies primarily on early and appropriate treatment of the initial symptoms. Here are some useful tips: 

• Have a hygiene and skincare routine that is suited to your skin type: avoid harsh or abrasive products that weaken the skin barrier. 
• Eat a varied and healthy diet to limit inflammatory factors.
• Have regular consultations and follow-ups with a dermatologist.