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Severe Acne: 4 types

Severe acne can affect many facets of a person’s life, causing a great deal of embarrassment and stress. Severe acne may significantly limit one’s social life and even interfere with opportunities for employment. Since this condition can be disfiguring and require years of treatment, it is important to see a specialist. Dermatologists have the most experience treating the different types of severe acne.

Four types of severe acne, described in detail below, are:

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      Acne conglobata
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      Acne fulminans
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      Gram negative folliculitis
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      Nodulocystic acne

Acne Conglobata
Acne conglobata is a chronic and severe form of acne vulgaris, characterized by:

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      Deep abscesses
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      Inflammation
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      Severe damage to the skin
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      Scarring
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      Blackheads (open comedones) are usually conspicuous and widespread—often occurring on the face, neck, trunk, upper arms and/or buttocks

In acne conglobata, inflammatory nodules form around multiple comedones, gradually increasing in size until they break down and discharge pus. Deep ulcers may form under the nodules, leading to keloid-type scars, and crusts may form over deeply ulcerated nodules

Burrowing abscesses commonly result in deep, irregular scarring.

Acne conglobata may be preceded by acne cysts, papules or pustules that do not heal, but instead rapidly deteriorate. Occasionally, acne conglobata flares up in acne that had been dormant for many years.

Males are more likely than females to have acne conglobata; the age of onset is usually between 18 and 30 years. The cause of the condition is not well understood.

Treatment. Isotretinoin is the usual treatment of choice for acne conglobata. Antibiotics may also be prescribed. Several courses of treatment may be necessary over a period of years. Even after effective treatment, the patient should have regular checkups by a dermatologist for any signs of recurrence. A dermatologist can also treat the scars.

Acne Fulminans
Acne fulminans is a sudden onset of highly destructive inflammation. It appears suddenly in a person with inflammatory acne and is characterized by:

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      Symptoms of severe and often ulcerating acne
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      Fever
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      Inflammation and aching of joints, especially hips and knees

A person who develops acne fulminans may have had unsuccessful treatment for another form of severe acne, acne conglobata.

Treatment. Corticosteroids or non-steroidal anti-inflammatory medications may be given to reduce inflammation. Attacks of acne fulminans may recur, and the patient may develop acne that requires long-term treatment with isotretinoin.

Nodulocystic Acne
Cysts are relatively uncommon in acne; however, this form of severe acne is characterized by cysts, which may measure several centimeters in diameter as seen in these two photos:


Cysts may develop singly or be widespread as these photos show


(Photos used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)

Cysts may occur singly, or be widespread over the face, neck, scalp, back, chest and shoulders. And, they can be painful.

The nodular cyst of acne is not a true cyst—an abnormal dilatation of a normal skin structure. Acne cysts are nodules of inflammation. The cysts may arise from a papular or nodular acne lesion, or occasionally from a type of cyst that develops in the outer layer of the skin—a type of cyst not usually associated with acne. A cyst may appear to be filled with thick, yellow pus-like fluid. This is usually an inflamed and infected cyst. If an attempt is made to drain such a cyst, it should be done in a physician’s office under sterile conditions, not in front of a bathroom mirror.

Cysts occurring close together may coalesce, producing soft areas undermined with tunnels, cell destruction and inflammation, resulting in another form of severe acne, acne conglobata.

Treatment. Nodulocystic acne usually requires an aggressive treatment regimen that may include isotretinoin and antibiotics, or intralesional corticosteroids that "melt" the cyst over a period of 3 to 5 days. Some very large follicular cysts that do not respond to medications may require drainage and surgical excision.

Gram-negative folliculitis
Gram negative folliculitis is an inflammation of follicles caused by a bacterial infection that can result from long-term antibiotic treatment. Patients who are being treated with antibiotics for severe acne may develop Gram negative folliculitis.

The word “Gram” refers to a blue stain used in laboratories to detect microscopic organisms. Certain bacteria do not stain blue and are called “Gram negative.”

Treatment. In Gram negative folliculitis, the bacteria are resistant to many antibiotics. Isotretinoin and antibiotics that are effective against Gram negative bacteria are used to treat this condition.

Anyone with severe acne should be under the care of a dermatologist as dermatologists have the experience needed to control virtually every case of acne.

It is important for patients and their families to know that severe, disfiguring forms of acne may require years of treatment and patients can experience one or more treatment failures. During treatment, the support of family and friends can greatly comfort patients. Information
s, such as AcneNet, may help family and friends to better understand what those with severe acne face every day.