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 aggravating.

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 of acne.

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

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.