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

Abstract

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.

Role of Tumor Necrosis Factor–α Inhibitors in the Treatment and Occurrence of Acne

“…An additional 42 articles were excluded following full-text review, resulting in 57 articles (Figure). Of these, 53 articles reported individual clinical data from 64 patients. The remaining 4 articles only provided grouped data rather than individual patient data, so these studies were omitted when calculating the following summary statistics.…”

Tumor necrosis factor‐α inhibitor treatment of acne fulminans – a clinical and literature review

“…8,12,[14][15][16][17]19 Antibiotics had been taken just prior to AF in 10/12 cases (83%). [8][9][10][11][12][13][15][16][17]19 Investigations Abrupt acne flares were described in 10/12 of cases (83%), [7][8][9][10][11][12][13][14]16,17 with hemorrhagic nodules/plaques in 10/12 (83%), [7][8][9][11][12][13][15][16][17] ulcers in 9/12 (75%), [7][8][9][10][11][12][13]16,17 crusts in 6/12 (50%), 7,8,11,12,17,19 and erosions in 3/12 (25%).…”

“…[8][9][10][11][12][13][15][16][17]19 Investigations Abrupt acne flares were described in 10/12 of cases (83%), [7][8][9][10][11][12][13][14]16,17 with hemorrhagic nodules/plaques in 10/12 (83%), [7][8][9][11][12][13][15][16][17] ulcers in 9/12 (75%), [7][8][9][10][11][12][13]16,17 crusts in 6/12 (50%), 7,8,11,12,17,19 and erosions in 3/12 (25%). 11,12,19 Concomitant symptoms were 9/12 (75%) arthralgias, 7,8,10,13,…”

“…and Streptococcus agalactiae. 12,13,19 Treatment All patients received median 4 (range 1-7), and, after referral to a dermatological department, 3 (range 0-6) systemic treatments for AF before initiating a TNF-α inhibitor treatment: 7/12 (58%) adalimumab; [8][9][10]12,13,15,17 3/12 (25%) infliximab; 7,11,19 and 1/12 (8%) golimumab or etanercept, respectively. 14,16 Anti-TNF-α therapy lasted median 7 months, and most patients received standard-dose psoriasis regimen, while only four received induction regimens, [7][8][9]12 and two the double-dose HS regimen.…”

“…14,16 Anti-TNF-α therapy lasted median 7 months, and most patients received standard-dose psoriasis regimen, while only four received induction regimens, [7][8][9]12 and two the double-dose HS regimen. 9,20 Seven of twelve patients (58%) received one or more concomitant treatments: Antibiotics 4/12 (33%), 11,12,15,19 prednisolone 3/12 (25%); 7,11,12 F I G U R E 2 Effect of anti-TNF-α therapy on skin symptoms in acne fulminans. methotrexate 2/12 (17%); 7,14 isotretinoin 2/12 (17%).…”