Acne, a pleomorphic disorder of the skin, is characterized by both less severe non-inflammatory lesions as well as the severe inflammatory type. Acne is mostly prevalent during adolescence – the most difficult period of physical and psychosocial development in the life of an individual.

Although not life threatening, acne vulgaris in its severest form has tremendous clinical, as well as psychological impact due to the severe inflammation and permanent residual scarring that can occur on the face, chest and back of the sufferer. This leads to feelings of low self esteem, social withdrawal, depression, anxiety and stress. Severity of this disorder thus causes both mental as well as physical discomfort.

Severe acne classified into four different subtypes

Four main subtypes of severe acne can be diagnosed. They are called; acne conglobata, acne fulminans, gram-negative folliculitis and nodulocystic acne.

Acne vulgaris

Acne vulgaris is the most common presentation of acne and the type of acne that most people experience. Acne vulgaris involves the initial development of comedones which are blackheads and/or white heads. Blackheads are plugs of sebum that build up in affected hair follicles where the plug is open to the skin surface. Whiteheads are also plugs of sebum in hair follicle canals but here the hair canal is closed over by dead skin. These comedones are non-inflammatory. However, when the comedones get bigger they may rupture the follicular walls. The immune system responds to the sebum and inflammatory papules, pustules and nodules are produced. These inflamed spots are the classic presentation of acne vulgaris.

Acne Conglobata

Acne conglobata is a chronic and severe form of acne vulgaris, characterized by deep abscesses, inflammation and widespread damage to the skin. Scarring blackheads or open comedones are found conspicuously and distributed thickly on the face, neck, trunk, upper arms and back. This form is unique in the formation of inflammatory nodules around multiple comedones that become bigger until they rupture and release pus. Ulcers and abscesses found beneath the nodules result in deep uneven scars and crust formation on the surface of the nodules. There may be the manifestation of acne cysts, papules or pustules preceding acne conglobata, which deteriorate instead of healing.

Acne Fulminans

Acne fulminans is characterized by a sudden occurrence of highly debilitating inflammation. Symptoms include severe and ulcerating acne, fever, inflammation and pain in the joints of hips and knees. Acne conglobata, when unsuccessfully treated, can give rise to this form of acne.

Nodulocystic Acne

This form of severe acne is characterized by cysts occurring in isolation or in thick clusters, on the face, neck, scalp, back, chest and shoulders. These measure several centimeters in diameter and are usually painful. These nodular cysts are nodules of inflammation arising from popular or nodular acne lesions or from cysts in outer epidermal layer. The inflamed and infected cysts contain yellow fluid and can occur close together often coalescing and resulting in cell destruction and acne conglobata.

Gram-negative folliculitis

Gram-negative folliculitis is an inflammation of follicles caused by a bacterial infection often resulting from prolonged antibiotic treatment. So patients who are being treated with antibiotics for severe acne may subsequently develop gram-negative folliculitis.

Acne in females

Acne is also more common amongst women with the onset of menarche. Many women experience this skin disorder due to ovarian or adrenal hyperandrogenism accompanied by severe sebum secretion starting in adulthood and occurring mostly before menstruation. In these cases, hormone therapy is considered to be effective.

Infantum or Pre-pubertal acne

Acne is sometimes found to occur in infants immediately after birth and present till they are 6 months of age. The cause of the acne is due to high levels of DHEA that has crossed the placenta from the mother into the baby shortly before birth. This type of acne is generally not treated as it clears up of its own accord as the mother’s DHEA is gradually metabolized.

Treatment of acne types

Isotretinoin and antibiotics are the usual treatment of choice for acne conglobata, nodulocystic acne and gram-negative folliculitis. Several courses of treatment may be necessary over a period of years. Corticosteroids or non-steroidal anti-inflammatory medications may be given to reduce inflammation in acne fulminans. Some very large follicular cysts that do not respond to medications may require drainage and surgical excision.