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Central Journal of Dermatology and Clinical Research

Case Report *Corresponding author

Acne Conglobata after Pregnancy


Zuzana Nevoralová, Acne Clinic, Department of
Dermatovenereology, Regional Hospital Jihlava,
Vrchlického 59, 586 33 Jihlava, Czech Republic,
Tel: 420 721104310; Fax: 420 567311266; Email:
Zuzana Nevoralová*
Department of Dermatovenereology, Regional Hospital Jihlava, Czech Republic Submitted: 21 July 2016
Accepted: 23 August 2016
Abstract Published: 25 August 2016

Acne conglobata is an uncommon and severe, inflammatory form of acne vulgaris that is Copyright
characterized by interconnecting abscesses, draining sinus tracts, and severe disfigurement. © 2016 Nevoralová
We present a case of a 26-year-old female with a past medical history of mild acne that
OPEN ACCESS
suddenly developed many papules, pustules, and fluctuant nodules on her face and back
after pregnancy that was consistent with a diagnosis of acne conglobata. Resolution of the
skin lesions was seen after treatment with oral steroids, antibiotics, and retinoids. Maintenance Keywords
therapy has been with topical retinoids. • Acne
• Conglobata
• Pregnancy
ABBREVIATIONS • Isotretinoin

AC: Acne Conglobata a combination of oral doxycycline (200 mg for five days followed
by 100 mg for ten days) and prednisone 20 mg orally to reduce
INTRODUCTION
inflammation. In addition to systemic therapy, topical therapy
Acne conglobata is a severe, inflammatory form of acne consisting of ichtoxyl with salicylic acid 2% was recommended.
vulgaris. On skin examination, one will characteristically find A rapid therapeutic response was noted within a few days of
interconnected abscesses, draining sinus tracts, scarring, and starting this therapeutic regimen. Thereafter, the steroid dose
severe disfigurement on the face, chest, arms and back. This was reduced by 5mg every week and isotretinoin 0.3 mg/kg/day
condition traditionally affects patients between the ages of 18 orally was started on week three of therapy.
to 30. The etiopathogenesis of this condition remains unclear;
At baseline, laboratory tests were within normal limits
however, it has a strong positive correlation with high levels of
(including CRP), only hypertriglyceridemia was present (3.13
testosterone and is most often seen in males. Treatment typically
mmol/l). On the face, redness, many papules and some pustules
includes oral isotretinoin and steroids. In the case presentation
to follow, we present a case of a 26-year-old female patient who
developed acne conglobata after pregnancy.

CASE PRESENTATION
A 26-year-old female referred to our Acne Clinic by a practical
dermatovenereologist because of a severe facial eruption that had
developed 6 weeks after giving birth. Her major concerns were
her appearance and the painfulness of the lesions. Past medical
history was significant for mild acne over the past 10 years along
with oral contraception use (ethinylestradiolum + dienogestum)
prior to pregnancy. The patient restarted her oral contraception
A) B)
two weeks prior to presenting to our clinic. Review of symptoms
was otherwise unremarkable. On physical examination, many
papules, pustules and fluctuant nodules were present on her face
and back (Figure 1). These findings led to a diagnosis of acne
vulgaris and treatment withoral amoxicillin/clavulanate, topical
erythromycin and ichtoxyl was initiated.
At her follow-up visit, there was no improvement on the
aforementioned therapeutic regimen. C-reactive protein (CRP)
levels and cultures of the pustules were done. CRP levels were
normal and no growth was noted on the cultures. With a lack of
therapeutic response and the subsequent findings, a diagnosis C)
of acne conglobata was made. All previous medications were
stopped; and to reduce inflammation, the patient was started on Figure 1 The patient before the treatment.

Cite this article: Nevoralová Z (2016) Acne Conglobata after Pregnancy. J Dermatolog Clin Res 4(4): 1079.
Nevoralová (2016)
Email:

Central

and nodules were present (Figure 2). With respects to side effects, abscesses, and draining sinus tracts [1]. The comedones often
the patient only endorsed mild chelitis while taking isotretinoin. occur in a group of 2 or 3. Cysts contain foul-smelling seropurulent
Hypertriglyceridemia was present on follow-up labs, but it did material that returns after drainage. Sinustracts persisting for
not worsen (3.76 mmol/l at maximum). The dose of isotretinoin an extended period of time can be present. When the lesions do
was increased to 0.5 mg/kg/day after one month of therapy; eventually heal, they leave scars that can be the usual type of acne
cumulative therapeutic dosewas130mg/kg for the entire 9 scar (atrophic) or can be the raised bump normally left behind
month treatment course. At the end of the isotretinoin treatment, by a burn or a cut (hypertrophic) interconnecting abscesses and
only small redness and slight scars on the cheeks were present irregular scars (both hypertrophic and atrophic), often producing
(Figure 3), which improved greatly with repeated dermaroller pronounced disfigurement. Usually the chest, the shoulders, the
treatments (Figure 4). She currently uses topical retinoids for back, the buttocks, the upper arms and the thighs are affected,
maintenance therapy. but there are also some reports of facial localization [2].
DISCUSSION It affects males more frequently than females. AC usually
occurs in young adults aged 18-30 years, but infants may develop
Acne conglobata (AC) is an uncommon form of acne that
this condition as well. It usually persists into the fourth decade
presents with numerous comedones, papules, pustules, nodules,
of life. AC may develop as a result of a sudden deterioration of
existing active papular or pustular acne, or it may occur as the
recurrence of acne that has been quiescent for many years.
Severe scarring produces psychological distress. Individuals
with this diagnosis are often ostracized and suffer from anxiety
and depression.
The cause of this condition is unknown, but it has been
associated with high levels of testosterone. It can be caused by
anabolic steroid abuse and sometimes appears in men after
finishing testosterone therapy [3]. It can also happen to someone
who has a tumour that releases large amounts of androgens [3],
A) B)
or to people in remission from autoimmune diseases, such as
leukemia. Severe AC can be associated with an XXY syndrome [4].
Figure 2 The patient before the isotretinoin treatment.
Normal HLA-A and HLA-B antigen frequencies have been found in
a series of 65 patients [5]. In certain persons, the condition may
be triggered by exposure to halogenated aromatic hydrocarbons,
halogen ingestion, thyroid medication, hypnotics, sedatives, or
lithium [6].
Treatment of acne conglobata can be challenging and
may require a combination of medicines. Topical treatment is
usually ineffective. The therapy of choice includes isotretinoin
0.5-1 mg/kg/day for 4-6 months along with simultaneous
use of systemic steroids, such as prednisone 1 mg/kg/day
for 2-4 weeks. Alternative therapies include oral tetracycline,
minocycline, or doxycycline. Oral tetracycline antibiotics should
A) B)
not be combined with oral isotretinoin because of an increased
risk of pseudotumorcerebri. For treatment of resistant cases,
Figure 3 The patient after the isotretinoin treatment.
dapsone 50-150 mg/day is recommended; this treatment should
be carefully monitored [7]. Treatment of AC with infliximab has
also been reported [8]. AC has even been successfully treated
with a combination of carbon dioxide lasers and topical tretinoin
therapy [9]. When severe AC is unresponsive to more accepted
options, modern external beam radiation may be an alternative
[10]. Intralesional triamcinolone or cryotherapy may also be
valuable [11]. Occasionally, surgical excision of interconnecting
large nodules may be beneficial [12].
Suicidal ideation, a concern in seemingly healthy adolescents,
should be anticipated in those with cosmetically disturbing skin
disorders, especially in adolescent males with AC [13]. It may
A) B) be wise to order routine screening for psychological disturbance
in adolescents with this diagnosis. Use of isotretinoin is not
Figure 4 The patient after repeated dermaroller treatments.
contraindicated in those with depression [14].

J Dermatolog Clin Res 4(3): 1079 (2016)


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Nevoralová (2016)
Email:

Central

Our case was clinically a typical example of acne conglobata. feature of the XXY phenotype: a report of five cases, review of all known
The affected person was female although AC usually affects XYY subjects with severe acne, and discussion of XXY cytodiagnosis.
men. The age of our patient was within normal limits. Facial Arch Dermatol. 1972; 105: 913-919.
localization was a less common one. A possible connection 5. Schackert K, Schola S, Steinbager-Rosental I. Acne of the fulminans
with hormonal changes after pregnancy as a trigger with our type following testosterone therapy in three excesivelly tall boys. Arch
patient was suggested. There is sparse information about acne Dermatol. 1988; 124: 414-417.
appearing during pregnancy or after delivery. Ratzer reviewed 6. Plewig G, Kligman AM. Acne conglobata. In: Plewig G, Kligman AM.
over 400 women about the influence of marriage, pregnancy and Acne and rosacea. Berlin: Springer. 2000; 294-307.
childbirth on acne vulgaris [15]. Pregnancy improved acne in 7. Tan BB, Lear JT, Smith AG. Acnefulminans and erythemanodosum
58%. After childbirth 75% of women reported an improvement, during isotretinoin therapy responding to dapsone. Clin ExpDermatol.
13% experienced no difference and 12% became worse. 1997; 22: 26-27.
Reviewing the literature, Ratzer found report of aggravation of
8. Shirakawa M, Uramoto K, Harada FA. Treatment of acne conglobata
acne in 2 patients during pregnancy, but no report of acne during with infliximab. J Am Acad Dermatol. 2006; 55: 344-346.
lactation. We found only one other reference of AC appearing
after pregnancy [16]. 9. Hasegawa T, Matsukura T, Suga Y, Muramatsu S, Mizuno Y, Tsuchihashi
H, et al. Case of acne conglobata successfully treated by CO(2) laser
CONCLUSIONS combined with topical tretinoin therapy. J Dermatol. 2007; 34: 583-
585.
Our case highlights a possible connection between hormonal
10. Myers JN, Mason AR, Gillespie LK, Salkey KS. Treatment of acne
changes after pregnancy and the development of acne conglobata.
conglobata with modern external beam radiation. J Am Acad Dermatol.
It is important to recognize this condition and its possible triggers. 2009; 6.
The sooner this condition is recognized, the sooner appropriate
therapy can be started and permanent disfigurement can be 11. Leyden JJ, Mills OH, Kligman AM. Cryoprobe treatment of acne
conglobata. Br J Dermatol. 1974; 90: 335-341.
avoided.
12. Weinrauch L, Peled I, Hacham-Zadeh S, Wexler MR. Surgical treatment
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Cite this article


Nevoralová Z (2016) Acne Conglobata after Pregnancy. J Dermatolog Clin Res 4(4): 1079.

J Dermatolog Clin Res 4(3): 1079 (2016)


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