Disfiguring Ulcerative Neutrophilic Dermatosis Secondary to Doxycycline and Isotretinoin in an Adolescent Boy With Acne Conglobata
Acne fulminans is an uncommon and debilitating disease that presents as an acute eruption of nodular and ulcerative acne lesions in association with systemic symptoms. It occurs commonly during treatment of severe acne (eg, acne conglobata) with isotretinoin in young adolescent male patients. Isotretinoin and doxycycline also can potentially induce development of neutrophilic dermatoses in patients with severe acne lesions, which are characterized by the acute appearance of painful ulcerative papulonodules accompanied by systemic symptoms including fever and leukocytosis. We report a challenging case of a 13-year-old adolescent boy who acutely developed hundreds of ulcerative plaques as well as systemic symptoms after being treated with doxycycline and isotretinoin for acne conglobata. He was treated with prednisone, dapsone, and colchicine and had to switch to cyclosporine to achieve relief from his condition.
Resident Pearl
- Doxycycline and isotretinoin have been widely used for treatment of inflammatory and nodulocystic acne. Although outstanding results can be achieved, paradoxical worsening of acne while starting these medications has been described. In patients with severe acne (ie, acne conglobata), initiation of doxycycline and especially isotretinoin at regular dosages as the sole treatment can impose devastating risks on the patient. These patients are best treated with a combination of low-dose isotretinoin (at the beginning) with a moderate dose of steroids, which should be gradually tapered while the isotretinoin dose is increased to 0.5 to 1 mg/kg once daily.
Comment
Thomson and Cunliffe5 reported a small case series of 11 young male patients with a mean age of 17 years who presented with severe worsening of their acne eruptions after taking isotretinoin, and they all responded well to an oral steroid. In another study, Bottomley and Cunliffe6 indicated that young male patients with notable acne on the trunk who are receiving a minimum dose of 0.5 mg/kg once daily of isotretinoin are at considerable risk for severe worsening of their skin condition.
Although severe worsening of acne lesions leading to acne fulminans or neutrophilic dermatosis secondary to isotretinoin or even doxycycline use is a rare entity, precautionary steps should be taken prior to treating acne conglobata patients with these agents. A review of PubMed articles indexed for MEDLINE using the terms acne, acne conglobata, and doxycycline revealed 2 prior cases of worsening acne in patients treated with doxycycline.7,8 Therefore, any patient presenting with acute worsening of an acne eruption while being treated with isotretinoin or doxycycline needs to be assessed for potential diagnosis of drug-induced acne fulminans or neutrophilic dermatosis.
It has been clearly documented in the literature that both doxycycline and isotretinoin can induce or exacerbate neutrophilic dermatoses in patients with severe underlying acne.6-8 The presentation may be mistaken for worsening acne, leading to inappropriate initiation or increase in the dose of isotretinoin therapy and worsening of the disease with potentially devastating disfiguring consequences. These patients tend to respond well to high-dose oral steroids alone or in combination with dapsone. A slow steroid taper over several months is recommended due to a high tendency for recurrence.
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