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  Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 2  |  Page : 93-95  

Hepatitis B, interferon, and acne fulminans in a young girl


1 Department of Dermatology, Army College of Medical Sciences, Base Hospital, Delhi, India
2 Department of Pathology, Army College of Medical Sciences, Base Hospital, Delhi, India
3 Department of Gastroenterology, Army College of Medical Sciences, Base Hospital, Delhi, India

Date of Web Publication4-Mar-2016

Correspondence Address:
Dr. Sandeep Arora
Department of Dermatology, Army College of Medical Sciences, Base Hospital, Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.178080

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   Abstract 

Acne fulminans (AF) is a very rare severe form of acne seen in young males, characterized by a sudden and explosive onset of hemorrhagic pustules and ulceration on the trunk, systemic features in the form of fever, polyarthropathy, malaise, erythema nodosum and painful osteolytic bone involvement with leukocytosis, and an elevated erythrocyte sedimentation rate. Conventional treatment of AF includes corticosteroids or immunosuppressive agents for the initial phase followed by isotretinoin. Active hepatitis B infection with a high viral load precludes the administration of any immunosuppressive drugs. We present the case of an 18-year-old girl with a history of occasional acne who presented with AF of sudden onset following administration of interferon-alpha-2a for her recently detected hepatitis B infection. Management of hepatitis B was withheld in view of her general condition. The patient was managed with low dose isotretinoin with subsidence of lesions. AF in a young female precipitated by interferon and its management with isotretinoin in the presence of active hepatitis B infection make the case unique.

Keywords: Acne fulminans, hepatitis B, interferon


How to cite this article:
Arora S, Malik A, Kumar D, Sodhi N. Hepatitis B, interferon, and acne fulminans in a young girl. Indian Dermatol Online J 2016;7:93-5

How to cite this URL:
Arora S, Malik A, Kumar D, Sodhi N. Hepatitis B, interferon, and acne fulminans in a young girl. Indian Dermatol Online J [serial online] 2016 [cited 2019 Dec 12];7:93-5. Available from: http://www.idoj.in/text.asp?2016/7/2/93/178080


   Introduction Top


Acne fulminans (AF) or acne maligna [1] is a very rare form of acne presenting with severe cutaneous and systemic manifestations in young males on the trunk, face, and rarely on the thighs [2] with sudden onset pustulation, hemorrhagic nodules with extensive crusting followed by severe scarring. These patients present with a short febrile illness, musculoskeletal pains, anorexia, weight loss, polyarthralgia, polyarthritis of the large joints, hepatosplenomegaly, and erythema nodosum. Investigations reveal elevated erythrocyte sedimentation rate, C-reactive protein, leukocyte count, and hepatic enzymes, and an increased uptake on bone scans, apart from leukemoid reaction., Hepatitis B infection is associated with vasculitis and lichen plans and interferon treatment has been reported to give rise to lupus/lupus-like lesions,[3] both associated with an underlying immunological response. AF has not been reported so far with interferon treatment.


   Case Report Top


An 18-year-old female, presented with sudden onset painful pustulation on the face with high-grade fever of two weeks duration with anorexia, myalgia, and polyarthralgia. She was recently detected to have active hepatitis B infection, for which she was administered interferon-alpha-2a 50 μg subcutaneously. She developed a sudden onset eruption of pustulation on the face over the next week, which progressed rapidly in number and into larger lesions accompanied by a high-grade fever ranging from 102–104°F with severe myalgia, asymmetric painful joints of the knees, elbows, and the wrists with anorexia. She gave a history of only intermittent facial acne prior to the present exacerbation. There was no history of any other drug intake prior to the aggravation nor did she have any other illness over the past six months. Her hepatitis B infection was detected incidentally during screening when her mother tested positive for hepatitis B.

Examination revealed a body temperature of 103°F. Dermatological examination revealed multiple pustules, with hemorrhagic crusting on the cheeks and the forehead [Figure 1]a. There was no pustulation on the back, chest, or shoulders. There was no regional lymphadenopathy, any other skin findings, clinical evidence of arthritis in the form of joint swelling or tenderness or hepatosplenomegaly.
Figure 1: (a) Acne fulminans at presentation, (b) after three weeks of treatment, and (c) after six months of stopping treatment

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Investigations showed an elevated erythrocyte sedimentation rate (36 mm), elevated C-reactive protein, leukocytosis (15,600 cells/mm 3) marginally elevated aspartate (45 U/L, normal range 9–35 U/L) and alanine transaminases (76 U/L, normal range 9–45 U/L), normal serum bilirubin, positive hepatitis B surface antigen, positive hepatitis B envelope antigen, hepatitis B (DNA) quantitative viral load RT-PCR 6.16 × 107 IU/mL and a normal alpha-feto protein level. Skin biopsy revealed dilatation and plugging of the follicular infundibulum with an intense mixed cellular infiltrate around the pilosebaceous units [Figure 2]. Pus culture from pustular lesions of the face did not reveal any bacterial growth at the end of 48 h. Blood cultures were also negative. Plain radiographs of joints, chest, and long bones did not reveal any abnormality initially as well after four weeks. Bone scans were not done. A hormonal profile comprising luteinizing hormone, follicle stimulating hormone, testosterone (free as well as total), dehydroepiandrosterone and 17-hydroxyprogesterone were normal. Ultrasound scans of the abdomen and pelvis were also normal.
Figure 2: Photomicrograph showing follicular plugging, sebaceous dilatation, and mixed cell infiltrate, H and E 10× and intense mixed cell perifollicular infiltrate, H and E, 40× (inset)

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Based on her history of explosive onset and progression of severe pustular acne, skin findings and systemic features, she was diagnosed as a case of AF. Her management for active hepatitis B infection was discontinued in view of her general ill health. Active hepatitis infection also precluded the use of immunosuppressive agents for AF. Oral isotretinoin 20 mg daily was started, following which she showed noticeable improvement over the next three weeks [Figure 1]b with subsidence of pustular lesions and reduction of erythema followed by complete resolution over the next four months. A follow up at six months revealed postacne scarring with no evidence of active acne [Figure 1]c. She has remained symptom free with no fresh acne lesions for six months after stopping isotretinoin (administered for three months).


   Discussion Top


AF is an extremely rare form of acne presenting with an explosive onset of painful, pustular, and ulceronecrotic lesions on the back, face, and the chest accompanied by constitutional features in the form of high-grade fever, polyarthralgias and polyarthritis involving the larger joints. It typically occurs in young males; occurrence in females is rarely described.[4] The exact etiology of AF is not known. An immunological basis is postulated with a specific cell-mediated immune response to Propionibacterium acnes.[5] This hypersensitivity reaction results in the severe cutaneous reaction, systemic features, as well as skeletal involvement in the form of aseptic osteolytic bone lesions most commonly involving the clavicles, sternum, and long bones,[6] which show up as irregular cortical erosions and periosteal reactions on plain radiographs and enhanced isotope uptake on bone scans.

AF has been reported in association with measles vaccination; inflammatory bowel disease; and drugs, such as tetracyclines, testosterone, and isotretinoin, either by neutrophil priming or increasing the fragility of the pilosebaceous apparatus resulting in an intense immunological response to P. acnes.[2],[4],[7]

Hepatitis B infection is managed with interferon during the active phase of the disease. Interferon is known to cause lupus/lupus-like lesions, whereas chronic hepatitis B infection is more often associated with essential mixed cryoglobulinemia, vasculitis, and lichen planus-like lesions.[3]

Management of AF relies on the use of systemic steroids with or followed by isotretinoin. Antibiotics have not been found to be useful. Nonsteroidal anti-inflammatory agents may be useful in case of musculoskeletal involvement. Other agents used successfully are cyclosporine alone, or in combination with systemic steroids and dapsone.[4],[8]

AF is a clinical diagnosis. Our patient, a young female with history of only occasional acne on the face with hepatitis B infection initiated on interferon-alpha-2a therapy had an obvious explosive break out of acne immediately thereafter. Her systemic features and laboratory parameters were consistent with the diagnosis. She however did not manifest any skeletal abnormalities on serial radiographs, although she did have asymmetric polyarthralgia. Her coexisting hepatitis management had to be discontinued in view of her general condition. She was initiated on isotretinoin as the best option for her AF as immunosuppression would have worsened her hepatitis B infection and dapsone would have been hepatotoxic.[8] Her response was good with cessation of fresh eruptions and subsidence of most of her AF lesions over a period of eight weeks. After three months of treatment, she was followed up for six months, during which time her skin lesions resolved with scarring and polyathralgia resolved without any sequelae.

A young female with hepatitis B infection, presenting with AF only on the face [9] precipitated by interferon-alpha-2a and its successful management with low-dose isotretinoin are the unique features of this case. The association of interferon and AF is not reported in literature so far to the best of our knowledge.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Jansen T, Plewig G. Acne fulminans. Int J Dermatol 1998;37:254-7.  Back to cited text no. 1
    
2.
Zanelato TP, Gontijo GM, Alves CA, Pinto JC, Cunha PR. Disabling acne fulminans. An Bras Dermatol 2011;86(Suppl 1):S9-12.  Back to cited text no. 2
    
3.
Grigorescu I, Dumitrascu DL. Spontaneous and antiviral-induced cutaneous lesions in chronic hepatitis B virus infection. World J Gastroenterol 2014;20:15860-6.  Back to cited text no. 3
    
4.
Karvonen SL. Acne fulminans: Report of clinical findings and treatment of twenty-four patients. J Am Acad Dermatol 1993;28:572-9.  Back to cited text no. 4
    
5.
Karvonen SL, Räsänen L, Cunliffe WJ, Holland KT, Karvonen J, Reunala T. Delayed hypersensitivity to Propionibacterium acnes in patients with severe nodular acne and acne fulminans. Dermatology 1994;189:344-9.  Back to cited text no. 5
    
6.
Laasonen LS, Karvonen SL, Reunala TL. Bone disease in adolescents with acne fulminans and severe cystic acne: Radiologic and scintigraphic findings. AJR Am J Radiol 1994;162:1161-5.  Back to cited text no. 6
    
7.
Sarifakioglu E, Onur O, Kart H, Yilmaz AE. Acute myopathy and acne fulminans triggered by isotretinoin therapy. Eur J Dermatol 2011;21:794-5.  Back to cited text no. 7
[PUBMED]    
8.
Wakabayashi M, Fujimoto N, Uenishi T, Danno K, Tanaka T. A case of acne fulminans in a patient with ulcerative colitis successfully treated with prednisolone and diaminodiphenylsulfone: A literature review of acne fulminans, rosacea fulminans and neutrophilic dermatoses occurring in the setting of inflammatory bowel disease. Dermatology 2011;222:231-5.  Back to cited text no. 8
    
9.
Yamanaka K, Tsuruta D, Kurokawa I, Ishii M, Kobayashi H. Unusual case of acne fulminans: Face predominant without chest and trunk lesion. Int J Dermatol 2009;7:1531-4.  Back to cited text no. 9
    


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