Acne isn’t an unfamiliar issue, at least not for the millions of people who experience it every year. The most common type of acne is acne vulgaris (AV), which comes in various forms, such as blackheads, whiteheads, and nodules.¹ While most forms of AV can be treated with over-the-counter acne skincare products, there's an exception that requires special attention: acne fulminans. Acne fulminans is a less docile form of AV that can bring on more severe side effects such as bone lesions, fever, and joint pain.²

Here we’ll get into the details of acne fulminans, sharing its symptoms, causes, and treatment options that are available.

What is acne fulminans?

If other forms of acne were your bullies, acne fulminans would be their even tougher older brother. Acne fulminans (AF) is a rare and severe form of acne vulgaris characterized by painful, acute, hemorrhagic, and ulcerating skin lesions. Unlike other types of acne, AF can elicit systemic symptoms like polyarthritis–the inflammation of multiple joints—and fever.³ So, you won’t be wrong to consider AF to be “more than” a skin condition since it can extend beyond the skin.

AF can sometimes be mistaken for another severe form of acne called acne conglobata (AC). However, you may tell AF from AC by the presence of cysts and acutely inflamed lesions. AF also lacks polyporous comedones—blackheads with multiple openings. It’s also worth noting that most people with acne fulminans have experienced acne—most likely in other forms—in the past.⁴

We'll discuss more distinguishing features of AF in a bit.

Key facts about acne fulminans

Acne fulminans is a rare condition, with fewer than 200 reported cases worldwide.⁵ Most times, the condition emerges suddenly and is resistant to conventional antibiotics used to treat acne.⁶ AF tends to appear as large, inflammatory plaques, nodules, and ulcers that may be covered by hemorrhagic crusting.⁷ Although it predominantly affects young Caucasian males between the ages of 13 and 22, females can also develop the condition.⁸

Symptoms and diagnosis of acne fulminans

You may experience these symptoms and skin changes if you have AF:⁹

• Painful plaques and nodules most likely located on the trunk

• Ulcers with crusting

• Joint pain in multiple joints

• Fever

• Stooped posture due to bone and joint pain

Note that other conditions can also bring on any of the above symptoms. So, you’ll need to undergo further tests to determine if you have AF or not.

Your healthcare practitioner may conduct the following tests to find out if you have AF:¹⁰

• Complete blood cell count (CBC).

• Erythrocyte sedimentation rate (ESR).

• Liver function tests (LFTs).

• C-reactive protein (CRP) test.

• Imaging, such as X-rays.

If you’re diagnosed with AF, your next line of action should be to treat and manage the condition effectively. We'll clue you in on the best ways to treat and manage AF shortly, but first, let’s dive into its causes.

Causes and risk factors of acne fulminans

What causes AF?

Medical practitioners don't fully understand the exact cause of acne fulminans. Scientists are still studying the condition to learn more. However, based on our current knowledge, taking high doses of isotretinoin—an oral medication used to treat severe acne—might trigger the condition. Isotretinoin makes it easier for the immune system to contact the acne-causing bacteria and other substances. This can cause inflammation in the skin of the acne patient which may eventually lead to AF.¹¹

Potential triggers and risk factors

According to clinical findings, you’re at risk of developing AF if you have increased testosterone levels. Increased steroid use may also trigger the condition.

Increased levels of testosterone 

High testosterone levels may lead to AF. This may explain why the condition is common among adolescent males as there's usually a testosterone increase in boys during puberty. Your risk of AF may also increase during testosterone therapy regardless of your serum testosterone levels.¹²

Use of anabolic steroids

Anabolic steroid use has been suggested as a trigger for AF.¹³ They are known to increase sebum levels on the skin and increase the amount of bacteria that cause acne.¹⁴

Additionally, certain antibiotics and genetic factors may play a role in the occurrence of AF.¹⁵

Treatment and management of acne fulminans

When treating acne fulminans, medical providers typically prescribe a combination of two drugs—corticosteroids and isotretinoin. First, the patient will likely take high doses of corticosteroids by mouth (0.5 to 1 mg/kg/day) for at least two weeks until the lesions heal.¹⁶ The treatment could last even longer if they have other symptoms. Then, the patient can start taking isotretinoin along with the corticosteroids. They could start with an initial dose of isotretinoin (0.1 mg/kg/day) for four weeks with the intention to continue it for another four weeks if there is no observable flare of symptoms. Over time, the goal is to reach a minimum total dose which is usually at least 120 mg/kg.¹⁷

Patients that stick to the treatment plan rarely have relapses. However, if they do, adjustments to the isotretinoin dose may be made. The treatment process usually lasts for several months because the initial dose of isotretinoin is low. During this time, the lesions should become smaller and less painful, and the inflammation should reduce. Scarring occurs in most cases.¹⁸

Other treatments

In addition to the usual treatment for AF with corticosteroids and isotretinoin, there are some other remedies that might help. These include:

• Topical corticosteroids: Applying creams with corticosteroids on the skin alongside the recommended treatment may make the acne get better faster.¹⁹

• Autoimmune drugs: For patients who don’t respond well to the usual treatments, certain drugs called biologics may help. Two examples are infliximab and etanercept. They work by targeting the immune system. However, it’s not clear if they work for everyone with AF.²⁰

• Laser treatment: A special type of laser called a pulsed dye laser may be moderately effective in managing AF. However, it doesn’t relieve pain. It can also lead to side effects like lighter skin patches or scarring. Also, it usually takes multiple laser treatments to achieve good results.²¹

• Diaminodiphenyl sulfone: Some healthcare practitioners believe diaminodiphenyl sulfone might help relieve acne symptoms in people with ulcerative colitis.²²

Some researchers have also succeeded in treating AF by combining a drug called prednisone with dapsone or cyclosporine.²³ Ultimately, you should consult your healthcare provider to learn what may be the best treatment option for you.

How to manage acne fulminans

You can manage acne fulminans with the help of a dermatology and/or internal medicine provider. If you’re a woman of childbearing age, you should be careful when using isotretinoin because the drug can potentially cause complications during pregnancy.²⁴ So, women receiving isotretinoin therapy should avoid becoming pregnant for at least one month after quitting the treatment.²⁵

It’s also crucial to keep your skin clean and dry and avoid applying unprescribed remedies, such as ointments and oils.²⁶

Additionally, smoking can worsen your acne, so it’s a good idea to stop smoking while you’re getting treated for AF.²⁷ (Or, even better, quit for good!) 

Traditional acne antibiotics are not recommended for treating AF, as they're ineffective.²⁸ Remember to follow the advice of your medical providers and take your medications as directed to help manage the condition.

Similar conditions associated with acne fulminans

There are other skin conditions that can be mistaken for acne fulminans. Let’s briefly look at some of them and identify their characteristics.

Acne conglobata (AC)

AC is a rare and severe type of acne that may appear on the face, upper body, back, thighs, and buttocks. It’s characterized by incredibly painful comedones, deep abscesses, and purulent cysts. A person with AC can also develop acne fulminans.²⁹

Rosacea fulminans

This is a rare skin condition that mostly affects women between the ages of 15 and 46.³⁰ Although uncommon, it can also affect children and men. It causes redness, papules, cysts, and painful bumps to appear on the skin. It is thought that hormones and in some cases, pregnancy, might be responsible for the condition.³¹

Prevent acne fulminans with an effective skin care routine 

Acne fulminans is a rare skin disorder. Although uncommon, you should be concerned if your acne is severely painful, bleeding, accompanied by fever, or doesn’t respond to over-the-counter acne medications. If your skin condition fits the description of acne fulminans, consult a licensed dermatology provider.

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P.S. We did the homework so you don’t have to:

1. Zaenglein, A.L., et al. Guidelines of care for the management of acne vulgaris. JAAD. (May 2016).

2. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. (2023, March 7).

3. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

4. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

5. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

6. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

7. Bhatia, J., et al. Acne Fulminans: A Case Report and Review of Literature. Indian Journal of Paediatric Dermatology. (January-March 2021).

8. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

9. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

10. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

11. Bhatia, J., et al. Acne Fulminans: A Case Report and Review of Literature. Indian Journal of Paediatric Dermatology. Ibid.

12. Bhatia, J., et al. Acne Fulminans: A Case Report and Review of Literature. Indian Journal of Paediatric Dermatology. Ibid.

13. Bhatia, J., et al. Acne Fulminans: A Case Report and Review of Literature. Indian Journal of Paediatric Dermatology. Ibid.

14. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

15. Bhatia, J., et al. Acne Fulminans: A Case Report and Review of Literature. Indian Journal of Paediatric Dermatology. Ibid.

16. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

17. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

18. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

19. Bhatia, J., et al. Acne Fulminans: A Case Report and Review of Literature. Indian Journal of Paediatric Dermatology. Ibid.

20. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

21. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

22. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

23. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

24. Layton, A. The use of isotretinoin in acne. Dermato-Endocrinology. (May-June 2009).

25. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

26. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

27. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

28. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

29. Hafsi, W., et al. Acne Conglobata. StatPearls. (2023, June 1).

30. Coutinho J.C., et al. Rosacea fulminans: unusual clinical presentation of rosacea. ABD. (September-October 2016).

31. Coutinho J.C., et al. Rosacea fulminans: unusual clinical presentation of rosacea. ABD. Ibid.

32. Zito, P.M. and Badri, T. Acne Fulminans. StatPearls. Ibid.

Meredith Hartle is a board-certified Family Medicine physician at Curology. She earned her medical degree at Kirksville College of Osteopathic Medicine in Kirksville, MO.

*Cancel anytime. Subject to consultation. Results may vary.

Here at Curology, we currently focus on the diagnosis and treatment of acne, rosacea, and anti-aging concerns. We do not treat many of the conditions mentioned in this article. This article is for information purposes.

Written by

Curology Team

Medically reviewed by

Meredith Hartle, DO