Frank Po-Chao Chiu, Aaron Boyce
Acne fulminans (AF) is a rare, severe form of acne characterized by the development of painful, inflammatory nodules, pustules and haemorrhagic ulcers, often but not necessarily in association with systemic manifestations including fever, arthralgia, myalgia and blood abnormalities. It typically affects adolescent males and primarily involves the face, neck, arms, back and chest. The pathogenesis of AF is likely multifactorial and is suspected to include genetic susceptibility, altered immune responses, hormonal changes, infections and other iatrogenic causes. Treatment is difficult and first-line therapy has traditionally involved the use of isotretinoin with oral corticosteroids. When contraindicated or ineffective, other systemic agents have been trialled including dapsone, methotrexate or cyclosporine. For AF refractory to conventional therapies, use of certain biologic agents have recently emerged as potentially effective treatment options. Herein, we report the case of a 14-year-old male who developed isotretinoin-induced AF that was successfully managed with off-label use of Adalimumab. He presented with a 1-year history of severe cystic acne involving his face, chest and back, which was non-responsive to topical therapy and antibiotics. Within 2 weeks of commencing isotretinoin and despite concurrent oral prednisone, our patient developed painful pustules, haemorrhagic nodules and leukocytosis with associated malaise and lethargy. He was diagnosed with AF, which flared repeatedly despite minimal doses of isotretinoin, ongoing oral prednisone and antibiotics. Upon review of the current literature and considering the side effect profile of other systemic agents, he was commenced on Adalimumab. Within 6 weeks, our patient demonstrated clinical improvement and tolerated increased doses of daily isotretinoin without complication. He has continued improving after 6 months of treatment, without requiring oral prednisone or antibiotics. This case demonstrates the effectiveness of Humira as a newer, well-tolerated therapy for the treatment of AF in adolescent patients, where traditional treatments have been unsuccessful. Acne fulminans (AF) is a rare, severe form of acne characterized by the development of painful, inflammatory nodules, pustules and.