The treatment of acne fulminans: a review of 25 cases

Acne fulminans treatment: case report and literature review

Acne fulminans (AF), a severe acne variant primarily evident in adolescent males, is characterized by the sudden onset of severe and often ulcerating acne with fever and polyarthritis. A case of a 14-year-old initially treated with clindamycin and surgical debridement, highlights the complexity of AF, including challenges in diagnosis, treatment, and the importance of early dermatological consultation. Successful management was achieved through systemic therapy with retinoids and corticosteroids, resulting in significant improvement. This case underscores the necessity of a coordinated effort among dermatologists, endocrinologists, and rheumatologists for effective AF treatment, illustrating the critical role of timely diagnosis and comprehensive care in managing this rare and challenging condition.

Isotretinoin-associated acne fulminans: A multicentre, retrospective study of the European Academy of Dermatology and Venereology Task Force on Acne, Rosacea and Hidradenitis Suppurativa

BACKGROUND

Acne fulminans (AF) is a rare severe acne entity. Although occasionally reported, it is unclear whether AF development is associated with oral isotretinoin treatment.

OBJECTIVES

To investigate the occurrence of isotretinoin-associated AF, clinical characteristics and prognosis at follow-up.

METHODS

An international, multicentre, retrospective study was performed in eight hospitals following the call of the EADV Task Force on Acne, Rosacea and Hidradenitis Suppurativa (ARHS). Characteristics of patients treated with isotretinoin before the development of AF (isotretinoin-associated acne fulminans, IAF) were compared with non-IAF (NAF).

RESULTS

Forty-nine patients diagnosed with AF from 2008 to 2022 were included (mean age 16.4 years, SD 2.9, 77.6% male). Αrthralgias/arthritis occurred in 11 patients (22.9%). AF occurred without any previous acne treatment in 26.5% of the patients. Overall, 28 patients (57.1%) developed AF after oral isotretinoin intake (IAF group), while the remaining 21 patients (42.9%) developed AF without previous oral isotretinoin administration (NAF group). IAF occurred after a median duration of isotretinoin treatment of 45 days (IQR: 30, 90). Patients with IAF were more frequently male compared to patients with NAF (89.3% vs. 61.9%, respectively, p = 0.023). There were no differences in patients with IAF versus NAF in patient age, the duration of pre-existing acne, a family history of AF, the distribution of AF lesions or the presence of systemic symptoms or arthralgias. Regarding the management of AF, patients with IAF were treated more frequently with prednisolone (96.2%) compared to those with NAF (70%; p = 0.033) and less frequently with isotretinoin (32.1%) compared to NAF (85.7%; p < 0.001). At a median follow-up of 2.2 years, 76.4% of patients were free of AF and scarring was present in all patients.

CONCLUSIONS

No specific clinical or demographic characteristics of IAF compared with NAF could be detected, a fact that does not support IAF as a district clinical entity.

Non-syndromic and Syndromic Severe Acne in Adolescent Patients

Acne is a common skin disorder in adolescents. However, severe acne that is persistent and refractory to conventional treatment or has other associated symptoms should raise suspicion for non-syndromic or syndromic acne.

Acne Fulminans: A Narrative Review

Acne fulminans is a severe and rare form of inflammatory acne. Lesion severity and subsequent scarring has a negative impact on the patient's quality of life. We conducted a narrative review of the literature on acne fulminans based on a search for relevant English- and Spanish-language articles published in Medline. We included case reports and case series. The main aim was to describe the clinical and demographic characteristics of patients with acne fulminans. A secondary aim was to determine whether quality of life was affected by the site or extent of lesions. We reviewed 91 articles describing 212 cases of acne fulminans. The mean age of the patients (91.94% male) was 16.6 years. A personal and family history of acne vulgaris was reported for 97.63% and 54.90% of patients, respectively. A trigger was identified in 44.79% of cases. The main cause was pharmacologic (96.63%) and the main drug isotretinoin (65.28%). The sites most often affected were the face (89.31%), the posterior trunk (77.86%), and the anterior trunk (74.81%). The predominant disease subtype was acne fulminans with systemic symptoms (59.12%), which were mostly general (97.06%). Systemic corticosteroids were the most widely used treatment (81.03%). The impact of the disease on quality of life was reported for 2 patients. In conclusion, acne fulminans mainly affects the face and trunk of male adolescents with a history of acne vulgaris. The main subtype was acne fulminans with systemic symptoms, and most patients were treated with systemic corticosteroids. The effect of acne fulminans on quality of life is underreported.

[Translated article] Acne Fulminans: A Narrative Review

Acne fulminans is a severe and rare form of inflammatory acne. Lesion severity and subsequent scarring has a negative impact on the patient's quality of life. We conducted a narrative review of the literature on acne fulminans based on a search for relevant English- and Spanish-language articles published in Medline. We included case reports and case series. The main aim was to describe the clinical and demographic characteristics of patients with acne fulminans. A secondary aim was to determine whether quality of life was affected by the site or extent of lesions. We reviewed 91 articles describing 212 cases of acne fulminans. The mean age of the patients (91.94% male) was 16.6 years. A personal and family history of acne vulgaris was reported for 97.63% and 54.90% of patients, respectively. A trigger was identified in 44.79% of cases. The main cause was pharmacologic (96.63%) and the main drug isotretinoin (65.28%). The sites most often affected were the face (89.31%), the posterior trunk (77.86%), and the anterior trunk (74.81%). The predominant disease subtype was acne fulminans with systemic symptoms (59.12%), which were mostly general (97.06%). Systemic corticosteroids were the most widely used treatment (81.03%). The impact of the disease on quality of life was reported for two patients. In conclusion, acne fulminans mainly affects the face and trunk of male adolescents with a history of acne vulgaris. The main subtype was acne fulminans with systemic symptoms, and most patients were treated with systemic corticosteroids. The effect of acne fulminans on quality of life is under-reported.

Adalimumab in the Management of Isotretinoin-Induced Acne Fulminans: Report of a Case

Acne fulminans (AF) is a rare, acute, and severe form of acne vulgaris often associated with systemic symptoms. Its treatment is challenging and controversial. We report a case of isotretinoin-induced AF (IIAF) in a 12-year-old boy resistant to traditional therapies (oral steroids and isotretinoin). The patient was successfully treated with adalimumab that can be considered an effective off-label option in the treatment of resistant IIAF in children.

Acne fulminans

Acne fulminans (AF) is a rare and severe form of inflammatory acne presenting clinically with an abrupt outburst of painful, hemorrhagic pustules and ulceration, that may or may not be associated with systemic symptoms, such as fever, polyarthritis, and laboratory abnormalities. It typically affects male teenagers with a pre-existing acne. Although the pathogenetic mechanism has not been established yet, a role of genetic, abnormal immunologic response, drugs intake, hormonal imbalance and viral infection, as causal factors, has been identified. AF may occur as a single disease or may be associated with other disorders. Traditionally, AF has been classified, on the basis of the presence of systemic involvement, in "acne fulminans" and acne fulminans "sine fulminans," when no systemic involvement is present. Recently, four clinical variants have been proposed: acne fulminans with systemic symptoms (AF-SS), acne fulminans without systemic symptoms (AF-WOSS), isotretinoin-induced acne fulminans with systemic symptoms (IIAF-SS), isotretinoin-induced acne fulminans without systemic symptoms (IIAF-WOSS). The diagnosis of AF is usually based on clinical history and physical examination. No specific laboratory abnormalities are generally found. In selected cases, biopsy and/or radiologic imaging are helpful for a correct diagnosis. The treatment significantly differs from severe acne according to severity of clinical presentation and possible systemic involvement. Currently, systemic corticosteroids (prednisolone) and retinoids (isotretinoin) represent the first choice of treatment. Dapsone, cyclosporine A, methotrexate, azathioprine, levamisole, and biological agents such as anakinra, infliximab, adalimumab may be considered as alternative therapies in selected cases. Adjunctive topical and physical therapies may also be considered.

Acne in the first three decades of life: An update of a disorder with profound implications for all decades of life

Acne vulgaris is a chronic, inflammatory, skin condition that involves the pilosebaceous follicles and is influenced by a variety of factors including genetics, androgen-stimulation of sebaceous glands with abnormal keratinization, colonization with Cutibacterium acnes (previously called Propionibacterium acnes), and pathological immune response to inflammation. Acne can occur at all ages and this discussion focuses on the first three decades of life. Conditions that are part of the differential diagnosis and/or are co-morbid with acne vulgaris are also considered. Acne in the first year of life includes neonatal acne (acne neonatorum) that presents in the first four weeks of life and infantile acne that usually presents between 3 and 6 months of the first year of life with a range of 3 to 16 months after birth. Acne rosacea is a chronic, inflammatory, skin condition that is distinct from acne vulgaris, typically presents in adults, and has four main types: erythemato-telangiectatic, papulopustular, phymatous and ocular. Treatment options for acne vulgaris include topical retinoids, topical benzoyl peroxide, antibiotics (topical, oral), oral contraceptive pills, isotretinoin, and others. Management must consider the increasing impact of antibiotic resistance in the 21st century. Psychological impact of acne can be quite severe and treatment of acne includes awareness of the potential emotional toll this disease may bring to the person with acne as well as assiduous attention to known side effects of various anti-acne medications (topical and systemic). Efforts should be directed at preventing acne-caused scars and depigmentation on the skin as well as emotional scars within the person suffering from acne.

Acne fulminans and Cutibacterium acnes phylotypes

BACKGROUND

Acne fulminans (AF) is a rare and severe form of inflammatory acne. It is characterized by a sudden worsening of acne with appearance of ulceronecrotic lesions, which can be associated with systemic signs. Its pathophysiology and the best therapeutic strategy are only partially known.

OBJECTIVE

Our main objectives were to describe the clinical and biological profile of AF patients and to determine whether there was a difference in Cutibacterium acnes phylotype in AF compared to acne vulgaris. The secondary objective was to assess the efficacy of different therapies.

METHODS

A retrospective observational study was conducted in all patients followed for AF in our department between 2008 and 2018. Bacteriological samples were taken from each patient to analyse C. acnes phylotype distribution. The therapeutic response was assessed using the ECLA and GEA scales.

RESULTS

Fifteen patients with a median age of 15 years were included (12 men, 80%). A family history of acne was found in 86.7% of patients. Nine patients (60%) had isotretinoin-induced AF. Only one patient (6.7%) showed systemic signs. The bacteriological culture was positive for C. acnes in 80% of patients. The predominant phylotype was IA1 in 60% of patients, corresponding to the predominant phylotype in acne vulgaris. Only 33.3% of patients were in remission after a first-line treatment with systemic corticosteroids, alone or in combination. Seven patients were treated with biotherapy, including five successfully with secukinumab.

CONCLUSION

Our results suggest that there is no specific C. acnes phylotype associated with AF, raising the hypothesis that acute inflammation associated with AF may be more related to an abnormal cutaneous innate immunity activation. The use of preventive strategies, the impact of combined treatments and an assessment of the role of biotherapies, especially anti-IL-17, in AF treatment remain to be more investigated.

Fulminant acne. Modern solution of the problem

Modern ideas about the etiological factors underlying a rare, serious illness — fulminant acne, the influence of genetic and exposure factors on the formation of the disease, and the pathogenesis of this form of acne are described. The main pathogenetic factors affecting the debut and course of fulminant acne were identified: Cutibacterium and the microbiome of the skin as a whole; sebum overproduction of sebum with the direct participation of dihydrotestosterone, progesterone, insulin-like growth factor-1; features of innate immunity, follicular hyperkeratosis. The clinic, complications and optimal therapeutic tactics at the present stage are described. A clinical case with a successful therapeutic outcome is presented.

A Novel Treatment of Acne Fulminans with Adalimumab: A Case Report

Acne fulminans (AF) is a rare and highly inflammatory severe form of acne most commonly seen in adolescent males. Unlike acne vulgaris, AF presents with associated systemic manifestations including, but not limited to, malaise, myalgia, arthralgia, fever, anorexia, and weight loss. It is often an extremely painful condition of sudden onset and can occur years after mild or moderate acne vulgaris. While the inciting agent for this condition has been postulated to be an explosive hypersensitivity reaction to the bacterium Propionobacterium acnes, increased androgens, namely testosterone, have also been reported to play a role in the pathogenesis of this disease process. Additionally, environmental triggers such as air pollution and exposure to halogenated hydrocarbons during occupational activities in enclosed, high temperature settings have been identified as possible etiologies or exacerbating factors. AF is primarily a clinical diagnosis. Isotretinoin, in combination with systemic steroids, are generally the treatments of choice for this disease entity. A Caucasian male in his early 40's presented to the authors' clinic with a chief complaint of painful acneiform nodules, cysts, papules, pustules, and abscesses on his back, chest, neck, shoulders, upper arms, and thighs for several months. This case report demonstrates a refractory case of AF with significant clinical improvement after six weeks of topical treatment with subcutaneous adalimumab in combination with oral doxycycline. This case provides evidence supporting the role of Adalimumab in the treatment of AF in addition to the other inflammatory conditions currently FDA approved for treatment with this tumor-necrosis factor (TNF) alpha inhibitor. These conditions include plaque psoriasis, Crohn's disease, hidradenitis suppurativa, psoriatic arthritis, and rheumatoid arthritis.

Successful Treatment of Facial Acne Fulminans: Antimicrobial Agents and Oral Prednisolone as Promising Regimes

Acne fulminans (AF), also known as acne maligna, is a rare painful ulcerative form of acne with an abrupt onset and systemic symptoms. Its incidence appears to be decreasing, possibly because of earlier and better treatment of acne. This report highlights a case on a necrotizing facial wound due to AF that was successfully treated with oral prednisolone and antimicrobial medication.

Management of severe acne

Acne is the most common skin disease, affecting up to 95% of adolescents. Severe episodes of acne can cause considerable physical and psychological scarring, and overexpression of transforming growth factor-β can lead to formation of hypertrophic scars and keloids. The severity of acne in adolescence is associated with a positive history of severe acne in first-degree relatives, especially the mother. In most cases acne is a chronic disease, and it is often a component of systemic diseases or syndromes. All forms of severe acne require systemic treatment. The available options include oral antibiotics, hormonal antiandrogens for female patients and oral isotretinoin, as well as other combination treatments. Oral isotretinoin is the only drug available that affects all four pathogenic factors of acne. However, due to possible serious side-effects, a European directive states that oral isotretinoin should be used only as a second-line therapy in cases of severe, nodular and conglobate acne. The pharmaceutical quality of generic isotretinoin products and the obtainability of isotretinoin through e-pharmacies without prescription raise new therapeutic problems. New anti-inflammatory compounds, such as the 5-lipoxygenase inhibitor zileuton, may replace systemic antibiotics in the future, especially under the scope of antibiotic resistance prevention. This review looks into the various options and latest approaches, and factors to consider, when combating severe acne.

Adverse effects of acne medications: recognition and management

Acne vulgaris is a very common chronic inflammatory disease of the skin. The clinical features of acne range from non-inflammatory comedones to inflammatory nodules. While often perceived as an adolescent disease, the prevalence remains high into adulthood, and the manifestations can have detrimental psychosocial effects. It is therefore not surprising that many patients are motivated to seek treatment. The existing treatment strategies for acne are complex due to the multifactorial pathogenesis of the disease. Although it is difficult to cure, four categories of medications have proved efficacious in reducing acne lesions: topical agents, systemic antibiotics, systemic retinoids, and hormonal agents. Unfortunately, these medications can cause adverse effects that may limit their use. Typically, these adverse effects are mild and transient and can be remedied by altering the dose or frequency of the offending agent. However, more serious adverse effects can occur that pose a significant health risk to the patient. Understanding how to recognize and manage the adverse effects of common acne therapies is imperative to providing the safest and most appropriate treatment for each patient. This article focuses on the recognition and management of adverse effects associated with current acne medications.

Pseudo-acne fulminans associated with oral isotretinoin

Acne fulminans is a rare and serious condition characterized by the sudden onset of nodular and ulcerative acne lesions associated with systemic symptoms. It has been recognized a subset of patients with a sudden worsening of acne, often during treatment with oral isotretinoin, but without the strong presence of systemic involvement. Recognized by some authors as "pseudo-acne fulminans" or " acne fulminans sine fulminans," we report a case with these features in order to draw attention to the recognition and early management of this manifestation.

The management of acne vulgaris in pregnancy

Acne vulgaris is a common condition in adolescence and also for many women of childbearing age. The management of acne in pregnancy is complicated by the lack of clinical studies and pharmacokinetic data in this patient population and safety concerns regarding retinoid use in pregnancy. Of primary concern to both patients and clinicians is the safety profile of medications used during pregnancy. This review seeks to clarify what management options are available to treat acne during pregnancy and what data are available to guide decision making. Topical treatments are considered the safest option during pregnancy. They have the best safety profile and minimize the levels of systemic absorption, and therefore the least risk of fetal exposure. If these are applied properly with a strong emphasis on adherence, excellent results can be achieved.

A case of acne fulminans presenting with systemic symptoms resembling acute appendicitis with maculopapular purpura-like eruption exacerbated by systemic steroids

Acne fulminans, the most severe form of acne, comprises ulcerative nodulocystic lesions with general, abdominal, and skeletal symptoms acute in onset. In our case, the patient initially had been managed as acute appendicitis. Antibiotic therapy had been administered in full doses with systemic corticosteroids, usually recommended as primary treatment. Few days later, we observed the complete palette of clinical manifestations (vasculitis-like lesions and joint pain) and the classic signs (nodules and pustules on face and chest) allowing the correct diagnosis. Our treatment was peculiar: a systemic antibiotic therapy, based on cephalosporines, proved to be effective.

Acne fulminans successfully treated with prednisone and dapsone

Acne fulminans is a rare condition and the most severe form of acne. It involves the sudden onset of febrile and multisystemic symptoms, with poor response to ordinary therapy in patients who previously had mild to moderate acne. It is characterized by hemorrhagic ulcerative crusting lesions on the face, chest and upper back. The authors report a case of acne fulminans that was successfully treated with oral prednisone and dapsone.

Acne fulminans and isotretinoin: case report

Acne fulminans (AF) is a rare disorder, the most severe form of the entire clinical spectrum of acne. It is characterized by emergence of painful inflammatory nodules that turn into ulcers, concomitant with systemic manifestations. It can be induced by isotretinoin and some authors believe that the occurrence of this condition is dose dependent. The treatment is controversial and there is no consensus up to this time. A case of this rare disease, developed during use of isotretinoin in low doses, is presented.

Zileuton, a new efficient and safe systemic anti-acne drug

Tissue inflammation is a major component of the acne process. Leukotriene B(4) (LTB(4)) is considered to be a major player in the development of tissue inflammation. Synthesis of LTB(4) is controlled by the enzyme 5-lipoxygenase. Since Zileuton blocks the activity of 5-lipoxygenase, experimental and clinical studies have been conducted to test mode of function, as well as efficacy and safety of this compound in the treatment of acne vulgaris. Human SZ95 sebocytes and inflammatory cells in vitro express the enzymes of the leukotriene pathway at mRNA and protein levels and enzymes involved in the biosynthesis of LTB(4) are activated in sebaceous glands of acne lesions. Pre-treatment of SZ95 sebocytes with Zileuton partially prevented short-term arachidonic acid-induced effects, such as induction of LTB(4), increase of neutral lipid content and stimulation of interlekin-6 release. Long-term treatment with Zileuton directly reduced the content of neutral lipids and interleukin-6 release from SZ95 seb ocytes. PPAR mRNA levels were not regulated by Zileuton. In a first pilot clinical study with 10 patients with papulopustular acne Zileuton 4 x 600 mg/d p.o. for 3 months decreased the acne severity index in a time-dependent manner being 41% of the initial score at week 12 (p < 0.05). This was mostly due to a decrease of the number of inflammatory lesions of 29% (p < 0.01). In addition, total sebum lipids significantly decreased (35%, p < 0.05) and the pro-inflammatory free fatty acids (22%) and lipoperoxides (26%) were markedly diminished in patients' sebum under treatment. The magnitude of clinical improvement strongly correlated with the reduction of total sebum lipids (p = 0.0009, r(2) = 0.81) and free fatty acids (p = 0.0003, r(2) = 0.82). In a further study, a 40-year-old female with mild disseminated sebaceous gland hyperplasia and seborrhea, responded with normalization of the casual skin surface lipids and similar reduction of facial sebum synthesis under treatment with Zileuton over 2weeks and-after a wash-out phase-low-dose isotretinoin (10 mg/2nd d) over 5 weeks. These data are in agreement with a phase II multicenter, clinical study in 101 patients with mild to moderate inflammatory facial acne conducted in the US, which showed a significant efficacy of Zileuton in a subset of patients with moderate acne, whereas those patients treated with Zileuton showed a significant mean decrease in inflammatory lesions compared to the placebo group. In all clinical studies, Zileuton was found to be safe and well tolerated.

A case of acne fulminans in a patient with ulcerative colitis successfully treated with prednisolone and diaminodiphenylsulfone: a literature review of acne fulminans, rosacea fulminans and neutrophilic dermatoses occurring in the setting of inflammatory bowel disease

A 19-year-old Japanese man had been treated for ulcerative colitis for 2 years. He was admitted to our hospital with nodulocystic inflammatory papules and pustules on his face and chest, high-grade fever, arthralgia and general malaise. A biopsy specimen from a pustule showed prominent infiltration of neutrophils in the epidermis and dermis, particularly around hair follicles. We made a diagnosis of acne fulminans. The systemic administration of prednisolone at 30 mg daily for 1 week immediately improved his skin lesions and other symptoms; however, during tapering of prednisolone at 20 mg daily, skin lesions flared up. The addition of oral diaminodiphenylsulfone improved the skin lesions. Although there have been a few reports of acne fulminans associated with Crohn's disease, this is the first case report of acne fulminans in a patient with ulcerative colitis. It is noteworthy that the addition of diaminodiphenylsulfone was effective for treating the relapse of acne fulminans in this case.

Therapeutic considerations for severe nodular acne

Severe nodular acne, defined as grade 4 or 5 acne on the Investigator's Static Global Assessment scale, is a skin condition characterized by intense erythema, inflammation, nodules, cysts, and scarring. Both the well known risk of physical scarring and the more recent recognition that acne can be a chronic, psychologically distressing disease with significant adverse effects on a patient's quality of life, have prompted earlier, more aggressive treatment with more effective medications, in the hope of preventing progression to more severe, nodular forms of the disease. Oral antibacterials, primarily tetracyclines, have long been the first-line therapy for severe nodular acne, which frequently remained refractory to therapy. However, concerns of antibacterial adverse effects, patient adherence, and antimicrobial resistance prompted the search for alternate therapies and combinations thereof in order to target the multifactorial pathogenesis of the disease. Isotretinoin, an oral retinoid introduced in 1982, has since become the gold standard therapy in severe acne and has revolutionized its treatment. Several adjunctive agents exist. Oral antibacterials are indicated as an alternative for patients with severe acne who cannot tolerate oral retinoids, or for whom a contraindication exists. In order to prevent bacterial resistance, antibacterials should always be used in combination with benzoyl peroxide, a nonantibiotic antimicrobial agent with anti-inflammatory activity. Topical retinoids are often added to this regimen. In women, hormonal agents, which include oral contraceptives, spironolactone, and oral corticosteroids, and, in Europe, cyproterone acetate, may be used as monotherapy or concomitantly with isotretinoin. For rapid treatment of inflammatory nodules, intralesional corticosteroids are effective. These treatment modalities have been studied, refined, and combined in novel ways in order to target the multifactorial pathogenesis of the disease, and in this article we review each of their roles.

Acne fulminans: explosive systemic form of acne

Acne fulminans (AF) is a rare severe form of acne vulgaris associated with systemic symptoms. It primarily affects male adolescents. Although the aetiology of AF remains unknown, many theories have been advanced to explain it. There have been reported associations with increased androgens, autoimmune complex disease and genetic pre-disposition. The disease is destructive, with the acute onset of painful, ulcerative nodules on the face, chest and back. The associated systemic manifestations such as fever, weight loss and musculoskeletal pain are usually present at the onset. The patients are febrile, with leucocytosis and an increased erythrocyte sedimentation rate. They may require several weeks of hospitalization. The treatment of AF has been challenging; the response to traditional acne therapies is poor. The recommended treatment is aggressive and consists of a combination of oral steroids and isotretinoin. To avoid the relapses, duration of such treatment should not be less than 3-5 months. Although the prognosis for patients treated appropriately is good, these acute inflammatory nodules often heal with residual scarring.

Skin disorders with arthritis

Many inflammatory, metabolic and infectious diseases affect the skin and joints. Most of these, such as rheumatoid arthritis and systemic lupus erythaematosus, are considered to be rheumatic conditions with secondary skin involvement. However, several primary cutaneous diseases are associated with arthritis and may even present with joint symptoms prior to cutaneous lesions. Common skin disorders, such as acne and psoriasis, have well-known musculoskeletal manifestations. Other less common conditions, such as dermatomyositis, multicentric reticulohistiocytosis, pyoderma gangrenosum, Sweet's syndrome and various cutaneous vasculitides, also have frequent joint involvement. This review will discuss the clinical presentation, both cutaneous and musculoskeletal, diagnosis and management of these disorders.

Peroxidated Squalene Induces the Production of Inflammatory Mediators in HaCaT Keratinocytes: A Possible Role in Acne Vulgaris

In order to investigate whether products derived from the oxidation of sebum can be responsible for the induction of inflammatory processes, HaCaT keratinocytes were treated with peroxidated squalene. NF-kappaB activation, secretion, and expression of IL-6, as well as peroxisome proliferator-activated receptor alpha (PPARalpha) mRNA and protein levels, were measured at the end of the treatment and after 24 and 48 hours of recovery. Squalene peroxidation products were administered in amounts able to elicit significant hyperproliferation and to induce lipoxygenase (LOX) activity. The results showed an early activation of NF-kappaB followed by an increase in PPARalpha mRNA and protein levels. Moreover, squalene peroxides induced an initial upregulation of IL-6 production and secretion that was counteracted by PPARalpha activation, as suggested by the subsequent decrease of NF-kappaB nuclear translocation and IL-6 levels. Inflammatory processes play an important role in the development of acne vulgaris. In combination with our own previous findings, which indicated an association between LOX stimulation and increased percentage of proinflammatory lipids in acne as well as a correlation between increased cytokine levels in the infundibulum, pilosebaceous duct hyperkeratinization, and augmented sebogenesis, the present data further support the involvement of lipid peroxides, in particular squalene peroxides, in establishing an inflammatory process in acne.

Therapie der Akne mit Antiandrogenen - Eine evidenzbasierte Ubersicht. Treatment of acne with antiandrogens - an evidence-based review

BACKGROUND

Increased sebaceous gland activity with seborrhea is one of the major pathogenetic factors in acne. Antiandrogen treatment targets the androgen-metabolizing follicular keratinocytes and the sebaceous gland leading to sebostasis, with a reduction of the sebum secretion rate of 12.5-65%. Antiandrogens can be classified based on their mechanism of action as androgen receptor blockers, inhibitors of circulating androgens by affecting ovarian function (oral contraceptives), inhibitors of circulating androgens by affecting the pituitary (gonadotropin-releasing hormone agonists and dopamine agonists in hyperprolactinemia), inhibitors of adrenal function, and inhibitors of peripheral androgen metabolism (5alpha-reductase inhibitors, inhibitors of other enzymes).

METHODS

All original and review publications on antiandrogen treatment of acne as monotherapy or in combination included in the MedLine system were extracted by using the terms "acne", "seborrhea", "polycystic ovary syndrome", "hyperandrog", and "treatment" and classified according to their level of evidence.

RESULTS

The combinations of cyproterone acetate (2 mg)/ethinyl estradiol (35 microg), drospirenone (3 mg)/ethinyl estradiol (30 microg), and desogestrel (25 microg)/ ethinyl estradiol (40 microg) for 1 week followed by desogestrel (125 microg)/ethinyl estradiol (30 microg) for 2 weeks showed the strongest anti-acne activity. Gestagens or estrogens as monotherapy, spironolactone, flutamide, gonadotropin-releasing hormone agonists, and inhibitors of peripheral androgen metabolism cannot be endorsed based on current knowledge. Low dose prednisolone is only effective in late-onset congenital adrenal hyperplasia and dopamine agonists only in hyperprolactinemia. Treatment with antiandrogens should only be considered if none of the contraindications exist.

CONCLUSION

Antiandrogen treatment should be limited to female patients with additional signs of peripheral hyperandrogenism or hyperandrogenemia. In addition, women with late-onset or recalcitrant acne who also desire contraception can be treated with antiandrogens as can those being treated with systemic isotretinoin. Antiandrogen treatment is not appropriate primary monotherapy for noninflammatory and mild inflammatory acne.

Acne and hirsuties in teenagers

Acne and body hair are both cutaneous responses to androgenic stimulation. They are normal events in adolescent girls. There is considerable variation in the evolution of the two conditions. The sebaceous gland is exquisitely sensitive to androgens, and acne appears with the onset of puberty, peaks in prevalence in the teenage years and gradually improves thereafter. Hair growth on the face, trunk and limbs develops more slowly and generally peaks in the 20s. Indications for endocrine investigation include very severe acne, onset of acne and hirsuties in the very early stage of puberty (Tanner stage 3) and systemic virilism. Treatment for acne and hirsuties can be either topical or systemic. The choice of therapy is based on the severity of the disease rather than the results of endocrine investigation. Further, since PCO is related to impaired glucose tolerance, advice relating to lifestyle changes should be offered to prevent the development of diabetes.