Acne is a pleomorphic disorder of the skin,
characterized by both less severe non-inflammatory comedones
to severe inflammatory lesions. During adolescence, the most
difficult period of physical and psychological development of
an individual’s life, prevalent acne can be extremely
Severe acne disorders causes both mental and physical discomfort.
The severe inflammation and permanent residual scarring due
to severe forms of acne vulgaris can occur on the face, chest,
and back, and although not life-threatening, this has tremendous
clinical and psychological impact on sufferers. The feelings
of low self-esteem, social withdrawal, depression, anxiety and
stress are few of the psychosocial problems acne can cause.
The Four Main Subtypes of Severe Acne
The four diagnosed main subtypes of severe acne are:
- acne conglobata
- acne fulminans
- gram-negative folliculitis
- nodulocystic acne.
Acne Vulgaris Type
This type is the most common presentation of acne and also
what most people experience. Acne vulgaris starts with the development
of comedones (blackheads or whiteheads). Affected hair follicles
are plugged with the built-up sebum. Blackheads are where the
plug is open to the skin surface, while whiteheads are also
plugs of sebum in hair follicle canals, but the hair canal is
closed by dead skin cells. These comedones are non-inflammatory,
but have the potential to rupture the follicular walls. When
this rupture occurs, the immune system responds to the sebum
by producing the inflammatory papules, pustules and nodules.
This is the classic representation of acne.
Acne Conglobata Type
This type of acne is characterized by deep abscess, inflammation
and widespread damage to skin; this is a chronic and severe
form of acne vulgaris. Scarring blackheads or open comedones
are often found conspicuously and distributed thickly on the
face, neck, trunk, upper arms and back. The formation of inflammatory
nodules around multiple comedones, that become bigger until
they rupture and release pus, proceeds from acne conglobata.
Deep, uneven scars and crust formation on the surface of the
nodules will result into ulceration and abscess beneath the
nodules. Preceding acne conglobota are acne cysts, papules or
pustules that deteriorate instead of healing.
Acne Fulminans Type
Untreated acne conglobata can give rise to acne fulminans.
This type of acne is characterized by a sudden occurrence of
highly debilitating inflammation. Its symptoms include severe
and ulcerating acne, fever, inflammation and pain in the joints
of hips and knees.
Gram-negative Folliculitis Type
An inflammation of follicles caused by a bacterial infection
often resulting from prolonged antibiotic treatment causes this
gram-negative folliculitis type of acne. Patients treated with
antibiotics for severe acne may subsequently develop this type
Nodulocystic Acne Type
This is severe type of acne characterized by cysts occurring
in isolation or in thick clusters on the face, neck, scalp,
back, chest, and shoulders. This type of acne is painful and
measures several centimeters in diameter. Nodular cysts are
formed from inflamed, popular or nodular acne lesions or from
cysts in outer epidermal layer. These inflamed and infected
nodular cysts contain yellow fluid, pus, and can occur close
together often coalescing and resulting in cell destruction
and acne conglobata.
Hormone Induced Female Acne
Women with the onset of menarche are also more prone to acne.
This type of acne is caused by ovarian or adrenal hyperandrogenism
accompanied by severe sebum secretion. Many women experience
this acne type starting in adulthood and occurring mostly before
menstruation. Hormone therapy is effective treatment for this
type of acne.
Infant acne occurs after birth and can be present till they
are 6 months of age. A high level of DHEA crossing the placenta
from the mother into the baby, shortly before birth, is the
cause of this type of acne. This type of acne usually does not
require treatment, as it fades away as the baby gradually metabolizes
the mother’s DHEA.
Treatment for Each Type of Acne
Acne conglobota, nodulocystic acne, and gram-negative folliculitis
are usually treated with isotretinoin and antibiotics. Sometimes,
acne may require several courses of treatment over a few years.
To reduce acne, fulminans inflammation corticosteroids or other
non-steroidal anti-inflammatory medications may be given. Drainage
and surgical excision maybe required for some very large follicular
cysts that do not respond to medications.