Severe, Sudden Acne Calls for Initial Prednisone

LAS VEGAS — Profoundly severe, sudden-onset acne in adolescents should be treated right away, Dr. Fred Ghali said.

These patients exhibit inflammatory and ulcerative acne lesions, often with large, nodular cysts, Dr. Ghali said at a dermatology seminar sponsored by Skin Disease Education Foundation. The face, chest, back, and shoulders are typically involved. And bleeding and associated tenderness are common complaints.

When you see such a patient from across the room, your first inclination may be to wonder why the patient waited so long to seek help, but in fact, these cases may have a sudden onset, said Dr. Ghali, a pediatric dermatologist in private practice in Grapevine, Tex.

For unknown reasons, these extreme acne blowouts tend to occur predominantly in boys about 10-15 years old.

Although isotretinoin will ultimately be the choice of therapy, management of such patients should start with oral prednisone to reduce the inflammation and potential for granulation tissue, he said.

In such cases, Dr. Ghali said he typically prescribes 40-50 mg of prednisone daily, tapering the dose over a period of several weeks. For more localized lesions, intralesional steroids can be used as well, he added.

Given either adjunctly or after a few weeks, low-dose isotretinoin can be initiated at 10-20 mg/day. This lower-than-standard daily dose of isotretinoin will hopefully avoid a further flare of inflammatory lesions and typically should be maintained for a few months; after that, step-up therapy to 20-40 mg/day can be used, followed by higher doses, introduced gradually as tolerated by the patient, Dr. Ghali said.

To achieve long-standing improvement, acne patients typically require a total isotretinoin course of 150 mg/kg. Patients with severe, sudden-onset inflammatory acne are no different and should receive at least the standard total course or sometimes even greater amounts over time if necessary, depending on the severity of the case and the patient's response.

“What if it takes 8-10 months to complete the course in some patients? So be it,” Dr. Ghali said. For these severely inflamed acne patients, the main issue is ensuring they receive an adequate cumulative course of isotretinoin, rather than attempting to complete the treatment within the 5-month treatment window that applies to most acne patients.

If the diagnosis is truly acne fulminans, arthralgia can be treated with NSAIDs. A longer course of oral prednisone may be required, he said. Again, isotretinoin should be initiated at a low dose for best results, and gradually increased over time.

Dr. Ghali reported no relevant conflicts of interest in regard to his presentation.

SDEF and this news organization are owned by Elsevier.

Inflamed lesions may appear explosively, as on the chest of this teenage boy. Lesions are usually tender and bleed. Courtesy Dr. Fred Ghali

LAS VEGAS — Profoundly severe, sudden-onset acne in adolescents should be treated right away, Dr. Fred Ghali said.

These patients exhibit inflammatory and ulcerative acne lesions, often with large, nodular cysts, Dr. Ghali said at a dermatology seminar sponsored by Skin Disease Education Foundation. The face, chest, back, and shoulders are typically involved. And bleeding and associated tenderness are common complaints.

When you see such a patient from across the room, your first inclination may be to wonder why the patient waited so long to seek help, but in fact, these cases may have a sudden onset, said Dr. Ghali, a pediatric dermatologist in private practice in Grapevine, Tex.

For unknown reasons, these extreme acne blowouts tend to occur predominantly in boys about 10-15 years old.

Although isotretinoin will ultimately be the choice of therapy, management of such patients should start with oral prednisone to reduce the inflammation and potential for granulation tissue, he said.

In such cases, Dr. Ghali said he typically prescribes 40-50 mg of prednisone daily, tapering the dose over a period of several weeks. For more localized lesions, intralesional steroids can be used as well, he added.

Given either adjunctly or after a few weeks, low-dose isotretinoin can be initiated at 10-20 mg/day. This lower-than-standard daily dose of isotretinoin will hopefully avoid a further flare of inflammatory lesions and typically should be maintained for a few months; after that, step-up therapy to 20-40 mg/day can be used, followed by higher doses, introduced gradually as tolerated by the patient, Dr. Ghali said.

To achieve long-standing improvement, acne patients typically require a total isotretinoin course of 150 mg/kg. Patients with severe, sudden-onset inflammatory acne are no different and should receive at least the standard total course or sometimes even greater amounts over time if necessary, depending on the severity of the case and the patient's response.

“What if it takes 8-10 months to complete the course in some patients? So be it,” Dr. Ghali said. For these severely inflamed acne patients, the main issue is ensuring they receive an adequate cumulative course of isotretinoin, rather than attempting to complete the treatment within the 5-month treatment window that applies to most acne patients.

If the diagnosis is truly acne fulminans, arthralgia can be treated with NSAIDs. A longer course of oral prednisone may be required, he said. Again, isotretinoin should be initiated at a low dose for best results, and gradually increased over time.

Dr. Ghali reported no relevant conflicts of interest in regard to his presentation.

SDEF and this news organization are owned by Elsevier.

Inflamed lesions may appear explosively, as on the chest of this teenage boy. Lesions are usually tender and bleed. Courtesy Dr. Fred Ghali

LAS VEGAS — Profoundly severe, sudden-onset acne in adolescents should be treated right away, Dr. Fred Ghali said.

These patients exhibit inflammatory and ulcerative acne lesions, often with large, nodular cysts, Dr. Ghali said at a dermatology seminar sponsored by Skin Disease Education Foundation. The face, chest, back, and shoulders are typically involved. And bleeding and associated tenderness are common complaints.

When you see such a patient from across the room, your first inclination may be to wonder why the patient waited so long to seek help, but in fact, these cases may have a sudden onset, said Dr. Ghali, a pediatric dermatologist in private practice in Grapevine, Tex.

For unknown reasons, these extreme acne blowouts tend to occur predominantly in boys about 10-15 years old.

Although isotretinoin will ultimately be the choice of therapy, management of such patients should start with oral prednisone to reduce the inflammation and potential for granulation tissue, he said.

In such cases, Dr. Ghali said he typically prescribes 40-50 mg of prednisone daily, tapering the dose over a period of several weeks. For more localized lesions, intralesional steroids can be used as well, he added.

Given either adjunctly or after a few weeks, low-dose isotretinoin can be initiated at 10-20 mg/day. This lower-than-standard daily dose of isotretinoin will hopefully avoid a further flare of inflammatory lesions and typically should be maintained for a few months; after that, step-up therapy to 20-40 mg/day can be used, followed by higher doses, introduced gradually as tolerated by the patient, Dr. Ghali said.

To achieve long-standing improvement, acne patients typically require a total isotretinoin course of 150 mg/kg. Patients with severe, sudden-onset inflammatory acne are no different and should receive at least the standard total course or sometimes even greater amounts over time if necessary, depending on the severity of the case and the patient's response.

“What if it takes 8-10 months to complete the course in some patients? So be it,” Dr. Ghali said. For these severely inflamed acne patients, the main issue is ensuring they receive an adequate cumulative course of isotretinoin, rather than attempting to complete the treatment within the 5-month treatment window that applies to most acne patients.

If the diagnosis is truly acne fulminans, arthralgia can be treated with NSAIDs. A longer course of oral prednisone may be required, he said. Again, isotretinoin should be initiated at a low dose for best results, and gradually increased over time.

Dr. Ghali reported no relevant conflicts of interest in regard to his presentation.

SDEF and this news organization are owned by Elsevier.

Inflamed lesions may appear explosively, as on the chest of this teenage boy. Lesions are usually tender and bleed. Courtesy Dr. Fred Ghali