Tuesday, May 17, 2022

Do You Have It? Symptoms, Treatments and More

  • Acne conglobata is a rare form of inflammatory acne that develops deep beneath the skin to form large, pus-filled cysts that can cause significant pain, swelling and disfiguring scars
  • This is a severe skin disorder that requires dermatological intervention as it can quickly spread across the face, back and chest
  • Acne conglobata is sometimes confused with acne fulminans, another severe form of acne

Acne conglobata is a chronic, rare but serious form of inflammatory acne that presents with deep interconnecting tunneling abscesses. Pimples and papules form on the skin’s surface while tender nodules develop deep beneath the skin. 

While it may not be possible to avoid some scarring, with prompt attention, skin damage can be minimized. There are several treatments available to control symptoms; typically, this involves combination therapy that includes professional treatments such as laser therapy and topical retinoids. 

What Is Acne Conglobata? 

Acne conglobata is a persistent, rare skin disorder that is characterized by cysts and inflamed pimples, as well as nodules that develop deep beneath the skin. It can begin as a common breakout of acne then worsen over time. Initially, lesions form on the face and torso, as well as upper arms and buttocks. Breakouts tend to be more severe on the back. 

This bacteria causes pus to form as well as large ulcers which grow larger and discharge a foul-smelling pus.

This form of acne is related to the more common nodular acne, but causes long, tunneling wounds beneath the skin’s surface, called sinus tracts. Unlike nodular acne, acne conglobata breakouts create deep wounds that can bleed and spread quickly. It can cause severe scarring and disfigurement.

Symptoms 

There are some identifiable symptoms of acne conglobata including:

  • Deep abscesses
  • Hematic (bloody) crusts
  • Inflammation and swelling
  • Polyporus comedones (blackheads with more than one opening joined together under the skin)

Acne conglobata vs. acne fulminans 

Acne conglobata can easily be mistaken for acne fulminans because symptoms are so similar; in order to minimize damage to skin, it is vital that you see a dermatologist to accurately identify which skin disorder you have and receive the correct treatment. 

Acne fulminans is a sudden onset and severe form of inflammatory acne that typically presents in young males (between 13 and 22 years) with a history of acne. It’s thought to be triggered by high testosterone levels, anabolic steroid use and isotretinoin (a medication for severe, treatment-resistant acne). Genetic factors as well as abnormal immunological response are also implicated in its onset.

Acne fulminans symptoms include:

  • Deep ulcers that develop suddenly and are accompanied by a high fever and painful joints
  • Multiple inflammatory nodules on the chest and back that deteriorate into painful ulcers with oozing necrotic plaques (dead cells caused by bacterial infection)
  • Red and tender lumps in the fatty cells under the skin (erythematous neovascular nodules) 
  • An enlarged spleen, inflammatory arthritis in the hips and knees, bone pain (especially the hips and knees) and chronic bone inflammation

Both acne conglobata and acne fulminans present with inflammatory nodules primarily on the chest and back. However, acne conglobata can be differentiated from acne fulminans by the appearance of polyporus comedones and noninflammatory cysts. Lastly, acne fulminans breakouts tend to weep and develop more rapidly than acne conglobata.

What Causes Acne Conglobata? 

It is theorized that Cutibacterium acnes (formerly Propionibacterium acnes) bacteria plays an important role in the development of this skin disorder by triggering an immune response that causes a chronic inflammatory state. 

While science has not yet identified the direct causes, they have identified several variables associated with this skin disorder:

  • Anabolic steroid use
  • Genetics
  • Testosterone therapy withdrawal
  • Medications that contain iodine or bromide
  • Fragrances  that contain benzene, naphthalene, anthracene, and phenanthrene

Popping Acne Conglobata 

As with other types of acne, it’s important to not pop, touch or pick blemishes, especially inflamed pus-filled cysts. Not only can it cause further irritation but bacteria can spread and worsen an existing condition. 

As this form of acne produces large cysts filled with malodorous pus, popping can also prove unpleasant. It could also increase the incidence of scarring and disfigurement. 

Treatment Options

Acne conglobata is a serious form of acne and as such, requires management by a dermatologist; it is challenging to treat and is often treatment-resistant. This is due to its severity and ability to spread quickly.

That being said, there are a range of professional treatments that include oral and topical antibiotics as well as surgery.

Oral medications

Isotretinoin

Isotretinoin is the first line of treatment for moderate to severe acne. Belonging to the retinoid family of pharmaceuticals, it’s a derivative of vitamin A that reduces the size of sebaceous glands and sebum production. 

The starting dose is typically 1–2 mg/kg per day for 3-4 months which can achieve 60%–95% clearance of inflammatory acne. For systemic symptoms, your doctor may also prescribe a simultaneous course of steroids such as prednisone for several weeks. 

Your symptoms may worsen, but this is expected as isotretinoin speeds up skin cell turnover, which can cause the sloughed off cells to clog pores and prompt more breakouts. 

You might find your skin is drier and more photosensitive during the course of treatment. To counteract this side effect, drink plenty of water, apply moisturizer and wear a high SPF sunscreen. 

Other side effects include depression and anxiety; if you experience mood changes, see your doctor immediately. This drug is not prescribed for pregnant women or for those who wish to become pregnant.

Tetracycline

Tetracycline and related oral antibiotics, such as minocycline and doxycycline, effectively slow the growth of bacteria and reduce inflammation. 

This medication can cause a range of side effects, including upset stomach, vomiting, diarrhea, sore throat, thrush (oral and vaginal) and sensitivity to sunlight. Tetracycline is also contraindicated for pregnant women.

Topical medications

While topical treatments alone cannot resolve this type of acne, they can be used alongside prescribed medications to target pain and swelling, and achieve better outcomes.

  • Benzoyl peroxide is the cornerstone of acne therapy, often used in conjunction with antibiotics and retinoids. It works to combat acne breakouts by killing bacteria and unblocking pores. It is available in many over-the-counter (OTC) skin care products and can also be obtained in prescription strength 
  • Corticosteroid cream or hydrocortisone is a topical form of steroid treatment that calms inflammation associated with acne breakouts and helps reduce redness and swelling

Treatment-resistant options

If your acne doesn’t respond to conventional treatments, your doctor may prescribe Dapsone, a strong antibiotic gel that has anti-inflammatory properties. They may also choose adalimumab (Humira), an immunosuppressive medication injected subcutaneously that prevents inflammation at the cellular level.

Surgery

Two surgical procedures are used to treat acne conglobata if prescription treatments prove ineffective or if there is significant scarring and disfigurement. One involves excision of the affected cysts; the other, surgical skin planing followed by resurfacing. Skin grafts can also be an effective option for scar tissue. 

Professional treatments  

There are professional treatments available to effectively treat acne conglobata and the accompanying scars, which include:

  • Dermal fillers: Depressed scar tissue can be treated with dermal fillers such as purified bovine collagen which can soften the appearance of scarring safely and painlessly over several treatments
  • Ablative fractional CO2 lasers are very effective treatments for minimizing acne scars. They work by removing the entire top layer of skin; treatments can be easily customized according to need
  • Microneedling involves puncturing the skin with tiny needles to stimulate collagen production and reduce the look of atrophic scars

Takeaway 

Acne conglobata is a relatively rare form of inflammatory acne that can be painful and disfiguring. It can begin with a severe bout of acne vulgaris or can develop suddenly after a long acne-free period of time.

Cysts, lesions, pimples and nodules develop and connect deep beneath the skin on the face, trunk, upper arms and buttocks. These resist healing and form deep ulcers that fill with pus, deteriorate and cause scarring.

It is important to seek treatment from a dermatologist at the first sign of symptoms to treat the condition and prevent scarring; OTC options will not be effective against this type of acne. 

Available options include laser therapy and dermal fillers; retinoid-based oral medication or corticosteroid creams; and oral antibiotics in tandem with benzoyl peroxide products.

Sources

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  • Xu Y, Deng Y. Ablative Fractional CO2 Laser for Facial Atrophic Acne Scars. Facial Plast Surg. 2018 Apr;34(2):205-219. doi:10.1055/s-0037-1606096
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