18-Year-Old With Painful, Eroded Lesions

Differential Diagnosis

• Acne vulgaris
• Acne fulminans
• Folliculitis
• PAPA syndrome

Diagnosis

The correct diagnosis in this case is acne fulminans.  Acne fulminans is a rare, highly inflammatory, immunologically induced form of acne that occurs most often in male patients between the ages of 13 and 22 years. While the pathogenesis of acne fulminans is not fully understood, the main inciting antigen is believed to be from Cutibacterium acnes (formerly known as Propionibacterium acnes).  Risk factors include chronic, severe acne (mean duration of 2 years), isotretinoin use (usually in high doses), a positive family history, high testosterone levels, and history of anabolic steroid use.

What to Look For

• Lesions most commonly located on the trunk
• Lesions are large inflammatory nodules and friable plaques that may be associated with erosions, ulcers and hemorrhagic crusts
• Systemic symptoms may include fever, arthralgias, myalgias, fatigue, erythema nodosum and laboratory abnormalities

Pearls for Urgent Care Management

• Mainstays of treatment include several week course of prednisone and isotretinoin (for patients not on isotretinoin)
• If acne fulminans is caused by isotretinoin, discontinue isotretinoin
• If systemic symptoms are present, prednisone alone should be started initially
• Referral to dermatology should be considered

Acknowledgment: Image and case presented by VisualDx (www.VisualDx.com/jucm).

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