Acne Fulminans Induced By Anabolic Steroids
Clinical images of the case patient. A and B, The patient at the time of his first consultation shows severe acne fulminans with inflammatory nodules, pustules, and deep hemorrhagic ulcerations in the chest area and back. C and D, The same patient 6 months after treatment with oral prednisolone and isotretinoin shows extensive scarring.
A 22-year-old male amateur bodybuilder presented to our clinic with a 3-month history of severe acne lesions on his upper trunk and face, accompanied by arthralgia of several joints. He reported the use of anabolic androgenic steroids (AAS) (testosterone enanthate, trenbolone acetate, drostanolone propionate, and methandrostenolone) for 3 months to increase his muscle mass. Shortly after he discontinued AAS intake, he developed severe inflammatory acne with painful rupturing and draining inflammatory nodules, pustules, and hemorrhagic ulcerations on his upper trunk and face (Figure, A and B). Moreover, he described an immobilizing arthralgia of his right ankle and both shoulder joints, as well as general symptoms including fatigue and a 15-kg weight loss over the 6 weeks prior to presentation.
Treatment with several antibiotics had been attempted, including erythromycin, clindamycin, doxycycline, and flucloxacillin, but his condition did not improve. Treatment with isotretinoin, 20 mg/d, was stopped after 4 weeks because of an aggravation of skin lesions. He presented to our clinic while being treated with oral doxycycline, 100 mg/d, and prednisolone, 40 mg/d, for 1 week. Enlarged lymph nodes were palpable in the groin; fever was absent.
Laboratory examination showed leukocytosis (white blood cell count, 19 400/?L) and an elevated C-reactive protein concentration of 52.3 mg/L. (To convert white blood cells to number of cells × 109/L, multiply by 0.001; to convert C-reactive protein to nanomoles per liter, multiply by 9.524.) Magnetic resonance imaging of the patient's right ankle joint revealed soft-tissue edema and articular effusion. The diagnosis of AAS-induced acne fulminans was made, characterized by sudden onset, ulceration of lesions, fever, polyarthralgia, weight loss, and failure of usual antibiotic therapy.
In our clinic, doxycycline and prednisolone treatment were discontinued. The patient was treated locally with debridements, antiseptic wound dressings, and benzoyl peroxide ointments. A new systemic therapy with isotretinoin, 60 mg/d, was started 3 days later. Arthralgia was controlled by treatment with oral diclofenac, 100 mg/d. A continuous improvement with reepithelialization of ulcerations and reduction of purulent lesions and nodules was noted. After 3 months, the isotretinoin dose was reduced, after 6 months, isotretinoin therapy was discontinued. However, the formation of extensive and partly hypertrophic scars could not be prevented (Figure, C and D).
The illegal use of AAS is increasingly common even among leisure sports athletes. Doping prevalence among college athletes in the United States reportedly is 17% to 20%; among male amateur bodybuilders it is even as high as 80%. In addition to cardiovascular, hepatocellular, and psychological adverse effects, 43% of patients who abuse AAS develop androgen-induced acne. As derivatives of the hormone testosterone, AAS lead to hypertrophy of the sebaceous glands, increased sebum production, and increased density of the Propionibacterium acnes population.
Our patient developed AAS-induced acne fulminans with the typical unresponsiveness to systemic antibiotics. After initial therapy with oral prednisolone, 0.5 mg/kg, and debridements, a clinical response was achieved with isotretinoin, 0.75 mg/kg.
In conclusion, it is important for health care providers to keep in mind that androgen-induced acne is one of the most frequent symptoms of AAS abuse. The most important measure is the immediate termination of AAS administration. Increased public education is needed to curb AAS abuse and associated health risks.
Kraus SL, Emmert S, Schon MP, Haenssle HA. The dark side of beauty: acne fulminans induced by anabolic steroids in a male bodybuilder. Arch Dermatol 2012;148(10):1210-2. JAMA Network | Archives of Dermatology | The Dark Side of Beauty: Acne Fulminans Induced by Anabolic Steroids in a Male Bodybuilder
