- Acne Conglobata is a rare form of acne that develops deep beneath the skin to form large, pus-filled cysts that can cause significant pain, swelling, scarring and disfigurement.
- Requiring management by a dermatologist, it can quickly spread across your chest, back and face, creating deep tunneling wounds and thick skin-colored comedones.
- Acne Conglobata can look similar to severe inflammatory skin conditions, such as Acne Fulminans. Read on to discover the differences.
What Is Acne Conglobata?
Acne Conglobata (AC) is a chronic, rare inflammatory skin condition where acne cysts, lesions, inflammatory pimples and nodules develop deep beneath the skin’s layers – initially on your face and trunk but also on your upper arms and buttocks.
Acne Conglobata is related to the more common nodulocystic acne, but causes large ulcers and long, tunneling wounds under the surface of your skin, called sinus tracts. It can begin as a common breakout of acne vulgaris, steadily worsening over time.
Unlike other variants of nodulocystic acne, Acne Conglobata breakouts run together and join up with each other creating deep wounds that often bleed. It can cause serious scarring and, sometimes, disfigurement.
You can tell the difference between the more common forms of nodulocystic acne and Acne Conglobata by the co-appearance of cyst-like nodules and serious inflammation. Common symptoms include:
- Deep abscesses.
- Inflammation and swelling.
- Significant skin damage and scarring.
- Polyporous comedones (or blackheads with more than one opening joined together under the skin).
- Hematic or meliceric crusts.
The first sign that you might be suffering from Acne Conglobata is the emergence of acne cysts and pustules that refuse to heal normally. Sometimes you’ll notice an acne flare up, even through your acne has been dormant for a long time. Acne Conglobata breakouts tend to be more severe on your back.
Clogged bacteria, oil and skin cells form hard plugs in the pores and create inflammatory nodules. These tend to form around widely spread comedones (or blackheads), growing larger until they deteriorate and discharge unpleasant smelling pus. Deep ulcers may form under these nodules, generating keloid scars and a crust-like appearance. These can produce deep thin (atrophic) or thick (hypertrophic) scars over time.
In Acne Conglobata, widespread nodules may also produce large, skin-coloured or reddened and swollen looking comedones that can also transform into cysts over time. These aren’t your normal cysts – they don’t contain an epithelium tissue lining and regular cysts don’t connect together in the same way.
Acne Conglobata vs. Acne Fulminans
Sometimes Acne Conglobata and Acne Fulminans appear similar, so it’s vital you determine which one your symptoms match and seek treatment accordingly.
Acne Fulminans is a very sudden and severe immune system disease mostly presenting in young males (typically between 13 and 22 years) with a history of acne. It’s thought to be triggered by high testosterone levels, anabolic steroid use and isotretinoin (a medication for severe, treatment-resistant acne). Genetic factors can also play a part in its onset.
Acne Fulminans symptoms include:
- Deep ulcers that come on suddenly and are accompanied by a high fever and arthritis symptoms in multiple joints.
- Multiple inflammatory nodules on the chest and back that morph into painful ulcers with oozing necrotic plaques.
- Red, sore, and tender lumps in the fatty cells under the skin (erythematous neovascular nodules)
- An enlarged spleen, inflammatory arthritis in the hips and knees, bone pain (this especially affects the hips and knees), and chronic bone inflammation and pain (aseptic multifocal osteomyelitis).
Acne fulminans can also be the body’s dermatological response to a form of inflammatory bone arthritis (synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome.
Both Acne Conglobata and acne fulminans feature inflammatory nodules primarily appearing on the chest and back. However, Acne conglobate can be differentiated from acne fulminans by the appearance of polyporous comedones, non-inflammatory cysts and non-inflamed breakouts.
Acne fulminans breakouts tend to remain open, weep and develop more rapidly than Acne Conglobata.
What Causes Acne Conglobata?
Dermatologists still don’t know what causes Acne Conglabata. Studies have suggested the HLA-A and HLA-B genotypes may be involved, which accounts for why it tends to run in families. These genes are also found in Acne Conglobata patients who also present with hidradenitis suppurativa, a condition where small, painful lumps form underneath the skin’s layers as a result of skin rubbing together in the armpits, groin and breasts.
Other suggested causes include:
- Anabolic steroid use
- Testosterone therapy withdrawal
- Medications that contain iodine or bromide
- Adrenal gland tumours releasing androgens
- Aromatic (fragrant) hydrocarbons that contain benzene, naphthalene, anthracene, and phenanthrene
In rare cases, Acne Conglobata has been linked with pyogenic arthritis (serious septic arthritis of a joint often caused by bacteria, a virus or fungus) and pyoderma gangrenosum (where large ulcers form on the legs). When presenting together, the diagnosis may be PAPA syndrome, a genetic condition in which a patient’s chromosome 15 is defective.
Popping Acne Conglobata
Like other forms of acne, it’s best to resist popping, touching or picking Acne Conglobata. It’s unlikely to improve your condition and your hands can transfer bacteria to the site, causing further complications like infection.
Because Acne Conglobata produces large cysts filled with malodorous pus, popping can also prove unpleasant and embarrassing. And it could also increase the scarring and disfigurement of your skin.
Acne Conglabata is a serious form of acne that requires management by a dermatologist. It’s challenging and complex to treat because the ulcers form deeply underneath the skin’s surface and spread quickly, making topical treatments ineffective. And, because it can co-present with other conditions, it’s best to seek the guidance of a professional.
Isotretinoin, also known as Roaccutane, is the gold standard in Acne Conglobata treatment is. Belonging to the retinoid family of pharmaceuticals, it’s a derivative of vitamin A that reduces the amount of sebum (natural oil) your skin produces, the size of your sebaceous glands and comedone formation, and follicular colonization of Propionibacterium acnes. This, in turn, reduces the bacteria that thrives in and feeds on sebum in your pores, secreting wastes and fatty acids that irritate your sebaceous glands and help cause acne.
The starting dose is usually 0.5-1 mg/kg taken orally for 4-6 months. For systemic symptoms, your doctor may also prescribe a simultaneous course of steroids like prednisone for a few weeks. Your Acne Conglabata may get worse initially but don’t worry – you’ll generally see results in a week to 10 days. Ninety percent of patients have clear skin within 4 months.
You might find your skin is drier and more photosensitive during your course of Isotretinoin. Make sure you drink lots of water, moisturize carefully and wear a high-SPF sunscreen.
Other side effects include depression and anxiety – if you experience mood changes health it’s best to talk to your doctor straight away. Pregnant women or those who wish to become pregnant are also advised not to take Isotretinoin because it can harm a foetus.
Tetracycline, and related oral antibiotics such as Minocycline and Doxycycline, help slow the growth of bacteria and reduce inflammation. If your Acne Conglobata is moderate, mild but stubborn, or you’re unsuitable for Isotretinoin therapy, these are the likely next line of attack your dermatologist will take. These medications can cause a range of side effects, including an upset stomach, vomiting, diarrhea, sore throat, thrush (oral and vaginal) and sensitivity to sunlight. Tetracycline is also contraindicated for pregnant women.
Treatment resistant options
If your Acne Conglobata is resistant to the above treatments, your Dermatologist may try Dapsone – a strong antibiotic gel that has anti-inflammatory properties. They may also try an anti-TNF therapy such as adalimumab (Humira), an immunosuppressive medication injected subcutaneously that prevents inflammation at a cellular level.
Removing the infected nodules via surgery or suction can be a last resort if the above treatments don’t prove effective. Skin grafts can also be effective for significant scarring. Both options can relive the discomfort and embarrassment of Acne Conglobata.
Acne Conglobata won’t respond to topical treatments alone but you can use them alongside your prescribed oral medications to achieve better outcomes and improve your comfort. Just remember that nodulocystic forms of acne like Acne Conglobata spread deep so anything that targets the skin’s upper layers will likely be ineffective.
- Benzoyl peroxide is a common antimicrobial treatment that combats acne breakouts by reducing bacteria on the skin and unblocking pores. You can find it in a wide range of over-the-counter products, including cleansers, moisturizers, creams and lotions. However, your dermatologist can also prescribe it in greater strengths to complement your oral medications.
- Corticosteroid cream or hydrocortisone is a topical form of steroid treatment that calms inflammation because it resembles cortisol, the natural hormone our bodies use to relieve inflammation in times of stress. It won’t kill the bacteria associated with acne breakouts but may lessen redness and swelling.
As Acne Conglobata can be significantly disfiguring, sufferers tend to isolate themselves from others and develop anxiety and depression. If you do venture out, you might seek to hide your scars with layers of clothing that can cause excess humidity, making your condition worse.
Professional treatments that reduce scarring can help:
- Dermal fillers. When your lesions have healed, the appearance of scars can be improved with dermal fillers such as purified bovine collagen. Studies show directly implanting dermal fillers into the scars can soften the look of scarring safely and painlessly within three treatments.
- Cryotherapy. This relatively new technique to combat scars freezes a scar from the inside out. After administering a pre-treatment aesthesia such as lidocaine cream, professional will administer intralesional triamcinolone via injection to reduce scar appearance. While further research is needed, initial evidence shows this treatment to be both safe and effective with few side effects.
Acne Conglobata is a relatively rare form of inflammatory acne that can be both painful and distressing. It can begin with a severe bout of acne vulgaris or can develop suddenly after a long period of no acne.
Cysts, lesions, pimples and nodules develop and connect deep beneath the skin on your face, trunk, upper arms and buttocks. These refuse to heal in a normal way and continue to grow until they form deep ulcers that fill with pus, deteriorate and scar. Acne Conglobata can also produce extensive skin-coloured or red swollen comedones that connect together to form large lesions.
If you think you’re suffering from Acne Conglobata, it’s important that you see a dermatologist for treatment. Because this is an inflammatory form of acne, over-the-counter acne treatments alone will prove ineffective – you’ll likely need to take a retinoid-based oral medication or oral antibiotic in tandem with benzoyl peroxide lotions or corticosteroid creams.
If your Acne Conglobata is treatment-resistant, there are other options to try. Surgery and skin grafts can reduce the appearance, embarrassment and discomfort of the condition.
- Silva PC, Oliveira EF, Goldenzon AV, Silva PC, Rodrigues MC. Challenges in diagnosis and treatment of a case of SAPHO syndrome in. An Bras Dermatol. 2011 Jul-Aug;86(4 Suppl 1):S46-9. ncbi.nlm.nih.gov/pubmed/22068769?dopt=Abstract
- Tago, Osamu; Nagal, Yayoi; Matsushima, Yoichiro; Ishikawa, Osamu. (2011) A Case of Acne Fulminans Successfully Treated with Cyclosporin A and Prednisolone. DOI:10.2340/00015555-0796
- Gallo M, La Montagna G, Tirri G. Ankylosing spondylarthritis associated with acne conglobata. Rheumatol Int. 1989;9(2):91-3. ncbi.nlm.nih.gov/pubmed/2530614
- Cengiz, Fatma Pelin; Kemeriz, Funda (2016) Acne Conglobata. DOI:10.5772/67044
- NHS. (2019) Isotretinoin capsules (Roaccutane). nhs.uk/medicines/isotretinoin-capsules/
- Rigopoulos D, Larios G, Katsambas AD. The role of isotretinoin in acne therapy: why not as first-line therapy? facts and controversies. Clin Dermatol. 2010 Jan-Feb;28(1):24-30. doi:10.1016/j.clindermatol.2009.03.005
- Yiu ZZ, Madan V, Griffiths CE. Acne conglobata and adalimumab: use of tumour necrosis factor-α antagonists in treatment-resistant acne conglobata, and review of the literature. Clin Exp Dermatol. 2015 Jun;40(4):383-6. doi:10.1111/ced.12540
- Varnavides CK, Forster RA, Cunliffe WJ. The role of bovine collagen in the treatment of acne scars. Br J Dermatol. 1987 Feb;116(2):199-206. ncbi.nlm.nih.gov/pubmed/2950913
- O’Boyle, C. P., Shayan-Arani, H., & Hamada, M. W. (2017). Intralesional cryotherapy for hypertrophic scars and keloids: a review. Scars, burns & healing, 3, 2059513117702162. doi:10.1177/2059513117702162