Indian Journal of Dermatology
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CASE REPORT
Year : 2006  |  Volume : 51  |  Issue : 2  |  Page : 128-130
Successful management of acne fulminans with combination of minocycline and dapsone


Department of Dermatology and Sexually transmitted diseases, Lady Hardinge Medical College and Associated Shrimati Sucheta Kriplani and Kalawati Saran Children's Hospital, New Delhi-110001, India

Correspondence Address:
Bhawna Harjai
B-7, Pandara Road, New Delhi - 110003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.26936

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   Abstract 

Acne fulminans is a rare and unique variant of acne vulgaris and is characterized by a sudden, violent onset of tender, nodulo-cystic and ulcerocrusted lesions over the back and chest, with fever, arthralgia and weight loss, affecting predominantly adolescent males. The exact etiopathogenesis is unknown although a hypersensitivity reaction is the most accepted hypothesis. Systemic steroids alone or in combination with isotretinoin are the cornerstones of its treatment. The successful management of Acne fulminans in an Indian boy with a combination of minocycline (200 mg once a day) and dapsone (200 mg once a day) daily is reported. The efficacy of minocycline as an alternative to steroids in the management of acne fulminans is highlighted.


Keywords: Acne fulminans, Dapsone, Minocycline


How to cite this article:
Mendiratta V, Harjai B, Koranne RV. Successful management of acne fulminans with combination of minocycline and dapsone. Indian J Dermatol 2006;51:128-30

How to cite this URL:
Mendiratta V, Harjai B, Koranne RV. Successful management of acne fulminans with combination of minocycline and dapsone. Indian J Dermatol [serial online] 2006 [cited 2019 Nov 21];51:128-30. Available from: http://www.e-ijd.org/text.asp?2006/51/2/128/26936



   Introduction Top


Acne fulminans is a catastrophic, scarring disease characterized by a sudden appearance of massive, inflammatory tender nodulo-ulcerative lesions over the chest and the back, associated with fever and arthralgia, occurring exclusively in teenage boys.[1] The pathogenesis of this disease is unknown. Hypersensitivity,[2] delayed hypersensitivity response to Propioniobacterium acnes[3] and immune complex mediated mechanisms because of decreased complement levels[4] have been reported as some of its possible mechanisms. Some authors reported occurrence of reactive arthritis seen in patients of HLA-B27.[5]

Therapeutically acne fulminans does not respond to antibiotics alone and systemic glucocorticoids are required to control the explosive flare ups. Isotretinoin is beneficial along with prior administration of glucocorticoids.[6] Severe cases with frequent recurrences are treated with cytotoxic agents like azathioprine etc.[7] The side effect profile of the immuno-suppressive agents coupled with their cumbersome monitoring procedures, have led to an ongoing, constant search for safer and simpler alternatives.

Minocycline, a semisynthetic derivative of tetracycline having potent anti-inflammatory effect on account of inhibition of neutrophil chemotaxis[8] and inhibitory effect on the T-cell activation and cytokine release[9] has successfully been used for the management of a number of dermatological disorders. Suppression of synovial membrane inflammation by minocycline has been used for managing rheumatoid arthritis.[10]

We report a case of acne fulminans of moderate severity in an Indian boy and its successful management with a combination of minocycline and dapsone.


   Case Report Top


A 15 year old boy presented with the complaints of sudden eruption of erosio-crusted lesions along with multiple nodulo-cystic swellings over his back, associated with fever and left knee arthralgia. There was history of acne over the face and the back for which he was under treatment with Tetracycline and various topical preparations off and on, and many other systemic antibiotics, the nature of which is not known.

Clinical examination revealed an adolescent boy who was conscious and cooperative and was febrile (temperature 99.5 degrees F). There was no other abnormality on general physical examination. The left submandibular lymph nodes were enlarged (discrete, non tender, mobile, 0.5 x 1 cm). Cutaneous examination revealed presence of multiple, discrete to confluent erythematous to skin colored nodules of size 1.5 x 2.5 cm, with cystic consistency, some showing erosions and ulcerations covered with crusts, along with discrete to confluent papulo-pustular lesions distributed primarily over the entire upper back, extending down to the lower back [Figure - 1], with few lesions on the face. Interspersed with these were multiple sinus tracts. There was pain on flexion of the left knee joint. Systemic examination was normal. A clinical diagnosis of acne fulminans with a differential diagnosis of gram negative folliculitis was considered. Grams stain from the pustule showed abundant polymorphs but no organisms. The culture was sterile. X-ray of the left knee was normal.

The patient was put on tablet minocycline 100 mg twice daily awaiting the culture and sensitivity report, along with tablet dapsone 100 mg once daily. Within seven days 40% of the lesions showed healing with erosio- ulcerative lesions decreasing in size and the pustules drying up [Figure - 2]. The dose of dapsone was increased to 200 mg daily after 7 days and the patient showed 100% improvement in four weeks after which the dose of dapsone was gradually tapered to 150 mg for three weeks and 100 mg for four weeks. The patient was asked to stop dapsone after 3 months as there were no active lesions of acne and only residual scarring was present on the back. Minocycline was however continued for an additional four weeks without observing any untoward side effects.


   Discussion Top


The exact etio-pathogenetic mechanisms underlying Acne fulminans are unknown but its explosive onset, coupled with a febrile course in association with polyarthralgia and leucocytosis suggests a hypersensitivity reaction or a vasculitis.

The clinical manifestations need to be controlled with a potent anti-inflammatory agent, like systemic steroids especially in very severe cases or systemic steroids with isotretinoin. Majority of the patients do not respond to Tetracyclines and other antibiotics.

Minocycline has proved useful in the management of acne and related disorders but it has not been used for Acne fulminans in the past. We successfully treated a patient of Acne fulminans with minocycline in a dose of 100 mg twice daily along with dapsone 100 mg twice daily.

Minocycline is effective in inhibiting both humoral and cell mediated immunity. Its easy availability and better side effect profile than corticosteroids and isotretinoin make it a better choice for the management of cases of Acne fulminans of moderate severity.

The precise mechanism of action of minocycline remains unclear but possibly its immuno-modulating properties and the inhibitory action on inflammatory cytokines and polymorphonuclear cell chemotaxis may be responsible for its efficacy. So minocycline in combination with dapsone/steroids/other adjuvants may be an additional choice for the treatment of Acne fulminans.

 
   References Top

1.Goldschmidt H, Leyden JJ, Stein KH. Acne fulminans: Investigation of acute febrile ulcerative acne. Arch Dermatol 1977;113:444.  Back to cited text no. 1  [PUBMED]  
2.Farber EM, Clairborne ER. Acne conglobata, use of cortisone and corticotrophin in therapy. Calif Med 1954;81:76-8.  Back to cited text no. 2    
3.Rajka G. Cell mediated immunity and acne conglobata. Arch Dermatovener (Stockh) 1977;57:141-3.  Back to cited text no. 3  [PUBMED]  
4.Lane AM, Leyden JI, Spiegel RJ. Acne arthralgia. J Bone Joint Surg 1976;58A:637-75.  Back to cited text no. 4    
5.Davis DE, Viozzi FJ, Miller F, Biodgett RC. The musculoskeletal manifestations of acne fulminans. J Rheum 1981;82:317-20.  Back to cited text no. 5    
6.Strauss JS, Thiboutol DM. Diseases of the sebaceous glands. In : Fitzpatrick TB, Arndt KA, Clark WH Jr, Eisen AZ, Van Scott EJ, Vaughan JH, eds. Dermatology in General Medicine. 5th ed. McGraw Hill: New York; 1999. p. 769-84.  Back to cited text no. 6    
7.Leyden JJ, MC Ginley KJ. Tetracycline and minocycline treatment. Arch Dermatol 1982;118:19-22.  Back to cited text no. 7    
8.Akamastu H, Niwa Y, Kurokawa I, Masuda R, Nishijima S, Asada Y. Effect of subminimal inhibitory concentrations of minocycline on neutrophil chemotactic factor production in comedonal acne bacteria, neutrophil phagocytosis and oxygen metabolism. Arch Dermatol Res 1991;283:524-28.  Back to cited text no. 8    
9.Oxyama N, Inove M, Matsui T. Minocycline effects on the clinical symptoms in correlation with cytokines produced by peripheral blood mononuclear cells stimulated with streptococcal antigens in Behcet's disease, in Hamza M. ed, Behcet's disease. Tunis:Pub Adhoua, 1997, p 481-86.  Back to cited text no. 9    
10.Patel RN, Attur MG, Dave MN, Patel IV, Stuchin SA, Abramson SB et al . A novel mechanism of chemically modified tetracyclines:inhibition of Cox-2 mediated prostaglandin E2 production. J Immunol 1999;163:3459-67.  Back to cited text no. 10    


    Figures

[Figure - 1], [Figure - 2]



 

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    Abstract
    Introduction
    Case Report
    Discussion
    References
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