Acne fulminans is a rare and severe skin condition. It is more commonly observed in male adolescents than in other sex and age groups. The etiology of severe acne is still unknown; however, increase in the level of androgens, autoimmune factors, or even genetic factors might be implicated. Local symptoms include the acute onset of painful destructive pustules and nodules on the face, chest, back, and upper extremities. Systemic symptoms include weight loss, musculoskeletal pain, and fever. Laboratory investigations of patients may reveal leukocytosis or raised erythrocyte sedimentation rate or C-reactive protein level [1]. Treatment options are the same as other conventional acne treatments; although most of the time, they require steroid injections or isotretinoin [2,3]. Patients usually remain with residual disfiguring scars even after successful treatment [1].

A 16-year-old Chinese male secondary school student presented with intermittent (on and off) mild-to-moderate acne vulgaris evolving for less than one year. He had visited multiple general practitioners and specialist clinics over a period of two months. The previous treatments he received included Tetralysal 300 mg once daily, topical Clindamycin, Lysozyme, Augmentin 625 mg twice daily, and a short course of isotretinoin for 3 weeks. The patient did not experience any noticeable improvement with these medications. He also took Chinese herbal medicine, but his condition worsened. He was a non-smoker and non-drinker with an unremarkable medical history.

On physical examination, there were multiple pustules, nodules, ulcerations, and plaques with hemorrhagic golden yellowish crusts on both sides of the face, forehead, and chin (Fig. 1, 2; we received the patient’s consent form about publishing all photographic materials). No similar lesions were found at other parts of the body. The patient underwent five sessions of intense pulsed light treatment (Lumenis M22 OPT machine). The treatment parameters are summarized in Fig. 3.

Figure 1. Patient’s right face before the first session of intense pulsed light treatment.

Figure 2. Patient’s left face before the first session of intense pulsed light treatment.

Figure 3. Intense pulsed light treatment parameters.

Seven sessions of intense pulsed light treatment were made every 3–4 weeks. Physical manual compressive extraction of the comedones, pustules, and nodules was performed immediately after the light treatment. Topical antibiotics (fucidin cream) were applied twice daily to the wound after cleaning with normal saline. Sunlight protection cream application and strict sun avoidance to avoid post-inflammatory hyperpigmentation were recommended. Throughout the treatment course, oral tetracycline, topical antibiotics, and Retin-A cream were administered to the patient. No topical/oral steroids were administered. For personal reasons, no further follow-up could be performed despite the remarkable improvement (Fig. 4–6).

Figure 4. Patient’s right face before the third session of intense pulsed light treatment.

Figure 5. Patient’s right face before the fifth session of intense pulsed light treatment.

Figure 6. Patient’s right face before the seventh session of intense pulsed light treatment.

Intense pulsed light treatment involves the application of a non-coherent, non-convergent, polychromatic filtered light rays (from a flash lamp source) to the skin. Modification of various parameters and selection of filters allow flexibility in the treatment of photon absorption by chromophores (melanin, hemoglobin, and water) over a wider spectrum in the target tissues. Intense pulsed light acts as a photodynamic therapy for treating acne vulgaris [4]. Propionibacterium acnes produces photosensitive porphyrins (protoporphyrin IX and coproporphyrin III) during growth and proliferation in follicular units [5]. Photoinactivation of bacteria by these reactive free radicals leads to DNA damage and altered intracellular pH due to altered membrane permeability. Leakage of bacterial cellular contents after the destruction of the cytoplasmic membrane decreases the bacterial colony population. These porphyrins have a fluorescence absorption spectrum close to the ultraviolet and visible spectrum of light, with an emission peak at approximately 600 to 750 nm. The density of the colonized bacteria correlates with the fluorescence intensity [6].

Intense pulsed light emits yellow, green, and red light in a sequence of short pulses. Yellow/green light damages bacteria that live in the skin and causes acne [4]. The pilosebaceous glands that inhabit P. acnes are also damaged by the energy generated by the intense pulsed light [7]. Although blue light is the most effective wavelength for photoinactivation of P. acnes, red/green light is an alternative with a better penetration depth than blue light. Red light directly targets the overactive sebaceous glands that cause outbreaks of pustules and nodules. Red light also has the additional advantage of inhibiting inflammation by altering the release of cytokines from macrophages. Hence, the photo-stimulating effects also affect the healing and repair of treated areas [8,9].

Targeted heating deep in the skin causes the shrinkage of the inflamed sebaceous gland and helps prevent overproduction of sebum. The inductions of collagen synthesis and dermal collagen remodeling also aid in the reduction of acne scarring. Therefore, intense pulsed light is effective in treating nodulocystic acne [4]. Skin texture improvement with shrinkage of the enlarged skin pore apertures, reduction of blemishes and telangiectasia have also been reported [10,11].

High fluence has more photothermal and photochemical actions, whereas subnormal fluence has more photochemical and photoimmunological actions [12]. Combining systemic antibiotics with intense pulsed light can produce better and longer lasting results. Manual extraction of comedones provides immediate partial improvement. This is because P. acnes rapidly regenerates; thus, multiple treatments are required. Potential complications of intense pulsed light therapy include pain, burns, and post-inflammatory hyperpigmentation [4].

Intense pulsed light combined with conventional acne treatment is effective for treating acne fulminans. Further research is needed for the selection of optimal treatment parameters and evaluation of long-term sustained results and post-intense pulsed light-tissue histological changes.

The authors have nothing to disclose.