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The main aim of this study was to review the clinical and demographic characteristics of AF&#46; A secondary aim was to investigate whether quality of life is affected by the site or extent of lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Material and Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a narrative review of the literature on AF in patients with or without an associated autoinflammatory syndrome&#46; We included English- and Spanish-language case reports and series published in Medline-indexed journals&#46; We excluded articles written in a language other than Spanish or English&#44; articles other than case reports or series&#44; basic research studies&#44; and molecular studies&#44; even those that reported on a case of AF&#46; The search was conducted in PubMed &#40;Medline database&#41; using the search terms &#8220;acne&#8221; &#91;Medical Subject Headings&#93; AND &#8220;fulminans&#8221; and targeting all articles published up to January 7&#44; 2022&#46; No initial date limit was established&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The articles were selected by first screening the titles and abstracts of all articles retrieved by the search&#46; When it was not clear if the article was a case report or series&#44; the full article was accessed&#46; Articles not dealing with patients with AF were discarded after a full-text review&#46; All articles were reviewed independently by 2 authors &#40;IT and AB&#41;&#44; who then met in a face-to-face meeting to resolve any discrepancies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Information was collected on each article &#40;author&#44; title&#44; journal&#44; year of publication&#44; and number of patients&#41;&#44; demographics &#40;age&#44; sex&#41;&#44; clinical characteristics &#40;personal history of acne and duration&#44; 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The 2 researchers agreed on the initial selection of 79&#46;3&#37; of the articles&#59; 33&#47;169 articles presented discrepancies that required discussion&#46; After discussing the reasons for inclusion or exclusion in a face-to-face meeting&#44; the 2 researchers reached an agreement on all cases&#46; Ninety-one articles were finally included&#58; 74 case reports &#40;1 patient&#41; and 17 case series &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>2 patients&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The studies analyzed a total of 212 patients &#40;mean &#91;SD&#93; age&#44; 16&#46;6 &#91;3&#46;63&#93; years&#59; 91&#46;9&#37; male &#91;194&#47;211&#93;&#41;&#46; Overall&#44; 165&#47;169 patients &#40;97&#46;6&#37;&#41; had a past history of acne &#40;mean duration&#44; 19&#46;2 &#91;23&#46;4&#93; months&#41; and 14&#47;35 &#40;40&#37;&#41; had had severe acne&#46; A family history of skin disease was mentioned for 29&#47;51 patients &#40;56&#46;9&#37;&#41;&#46; Of these 29 patients&#44; 28 &#40;96&#46;6&#37;&#41; had had acne&#46; The most frequently affected family members were siblings &#40;57&#46;9&#37;&#44; 11&#47;19&#41; followed by parents &#40;42&#46;1&#37;&#44; 8&#47;19&#41;&#46; Mean time from onset of an AF flare to a physician visit was 4&#46;6 &#40;3&#46;9&#41; weeks&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The distribution of AF triggers is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; Drugs were mentioned as a trigger in 72&#47;73 patients &#40;98&#46;6&#37;&#41;&#46; Isotretinoin was the main drug involved &#40;65&#46;3&#37;&#44; 47&#47;72&#41;&#44; followed by tetracycline &#40;16&#46;7&#37;&#44; 12&#47;72&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The main sites for AF were the face &#40;89&#46;3&#37;&#44; 117&#47;131&#41;&#44; the posterior trunk &#40;77&#46;9&#37;&#44; 102&#47;131&#41;&#44; and the anterior trunk &#40;74&#46;8&#37;&#44; 79&#47;131&#41;&#46; The other sites are shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Hemorrhagic ulcers were the most common type of lesion &#40;58&#46;9&#37;&#44; 86&#47;146&#41;&#46; The prevalence of the other lesions ranged from 34&#46;9&#37; to 44&#46;5&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The main subtype of AF was AF with systemic symptoms not induced by isotretinoin &#40;AF-SS&#41; &#40;59&#46;1&#37;&#44; 81&#47;137&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Extracutaneous systemic manifestations were observed in 146&#47;169 patients &#40;86&#46;4&#37;&#41;&#46; The manifestations involved a single system in 43&#47;68 patients &#40;63&#46;2&#37;&#41;&#44; 2 systems in 22&#47;68 patients &#40;32&#46;4&#37;&#41;&#44; and 3 systems in 3&#47;68 patients &#40;4&#46;4&#37;&#41;&#46; The most common manifestations were general symptoms &#40;97&#46;1&#37;&#44; 66&#47;68&#41; followed by lymphadenopathy &#40;23&#46;5&#37;&#44; 16&#47;68&#41;&#46; The other organs and systems affected are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Overall&#44; 145&#47;180 patients &#40;80&#46;6&#37;&#41; had fever during the onset of AF&#44; 120&#47;126 &#40;95&#46;2&#37;&#41; had an elevated ESR &#40;mean&#44; 65&#46;4 &#91;28&#46;65&#93;<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#41;&#44; and 168&#47;186 &#40;90&#46;3&#37;&#41; had leukocytosis &#40;mean&#44; 15&#44;484&#46;90 &#91;3922&#46;38&#93;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span><span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Musculoskeletal involvement was mentioned for 152&#47;172 patients &#40;88&#46;4&#37;&#41;&#59; the main manifestation was arthralgia &#40;75&#46;3&#37;&#44; 143&#47;190&#41; followed by myalgia &#40;12&#46;2&#37;&#44; 17&#47;139&#41;&#46; Radiologic changes were observed in 73&#47;125 patients &#40;58&#37;&#41;&#46; Notable changes were increased uptake in scintigraphy &#40;31&#46;5&#37;&#44; 23&#47;73&#41; and osteolytic lesions &#40;27&#46;4&#37;&#44; 20&#47;73&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">An autoinflammatory syndrome was mentioned for 4&#47;146 patients &#40;2&#46;7&#37;&#41;&#58; 3 of the patients had SAPHO &#40;synovitis&#44; acne&#44; pustulosis&#44; hyperostosis&#44; and osteitis&#41; syndrome and 1 had PAPA &#40;pyogenic arthritis&#44; pyoderma gangrenosum&#44; and acne&#41; syndrome&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Systemic corticosteroids were the treatment of choice for 81&#37; of AF flares &#40;158&#47;195&#41;&#46; The next most common treatments were isotretinoin &#40;52&#46;3&#37;&#44; 102&#47;195&#41; and systemic antibiotics &#40;46&#46;2&#37;&#44; 90&#47;195&#41;&#46; A combination of systemic corticosteroids and isotretinoin was used in 90&#47;125 patients &#40;46&#46;2&#37;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Impact of AF on quality of life was reported for just 2 &#40;0&#46;9&#37;&#41; of the 212 patients analyzed&#46; Both patients had depression&#44; and a suicide attempt was mentioned for 1 of them&#46; Due to this very small subgroup&#44; we were unable to investigate the association between quality of life impairment and other variables&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The clinical and demographic characteristics of AF observed in this narrative review are largely consistent with findings to date&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our results confirm previous reports of a predominance of AF in adolescents and males&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> Practically all the patients &#40;97&#46;6&#37;&#41; in our review had a past history of acne&#44; demonstrating that absence of such a history is very rare&#46; Smaller series of 15&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 24&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> 25&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and 26<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> patients found that 100&#37; of patients with AF had a history of acne&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">An AF trigger was mentioned for 44&#46;8&#37; of patients analyzed in this review&#46; Drugs were the most common trigger &#40;98&#46;6&#37;&#41;&#44; with isotretinoin identified in 65&#46;3&#37; of cases&#46; Triggers described in the largest series to date vary considerably&#46; Bocquet-Tr&#233;moreux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> reported a pharmacologic trigger in 60&#37; of patients&#44; with isotretinoin responsible for all cases&#46; The rate in the series of 26 patients described by Massa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> was markedly lower&#44; at 12&#37;&#44; and none of the cases were associated with isotretinoin&#46; No triggers were observed for any of the 8 patients described by Goldschmidt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The most common sites for lesions in the studies reviewed in this series were the face &#40;89&#46;3&#37;&#41;&#44; the posterior trunk &#40;77&#46;9&#37;&#41;&#44; and the anterior trunk &#40;74&#46;8&#37;&#41;&#46; Other authors have reported a similar predominance of facial &#40;100&#37;&#41; and trunk &#40;87&#37;&#8211;88&#37;&#41; lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Hemorrhagic ulcers accounted for 58&#46;9&#37; of all AF lesions in our series&#46; The next most common lesions were nodules and cysts and papules and pustules&#46; Massa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported necrotic and ulcerating papules in all 26 patients analyzed&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Scarring was described in 5&#47;5 patients in the series by Meinzer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and in 0&#47;6 patients in that of Reunala et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In the studies in our review&#44; scarring was reported for 43&#46;8&#37; of patients&#46; These findings must be interpreted with caution&#44; as it can take time for residual scarring to develop after resolution of an AF flare&#46; Karvonen<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> indicated that while 82&#37; of patients no longer had active lesions after several years&#44; they did have residual scarring&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The pooled analysis of AF cases in our review showed that AF-SS was the most common subtype &#40;59&#46;1&#37;&#41;&#44; followed by isotretinoin-induced AF with systemic symptoms &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Other series show a different distribution&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8&#8211;11</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Overall&#44; 86&#46;4&#37; of patients had extracutaneous manifestations&#44; which were general &#40;nonspecific&#41; in 97&#46;1&#37; of cases&#46; Very few series of 5 or more patients in our review specified type of systemic manifestations&#46; Seukeran and Cunliffe<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported loss of appetite in 17&#47;25 patients &#40;68&#37;&#41; and weight loss in 9&#47;25 &#40;36&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> All six patients examined by Reunala et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> had general malaise&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Fever was present in 80&#46;6&#37; of the patients reviewed&#46; Other series have reported rates ranging from 92&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> to 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Just 9 &#40;35&#37;&#41; of the 26 patients described by Massa et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> however&#44; had fever&#46; Our findings for elevated ESR and peripheral leukocytosis are consistent with rates in the literature of 92&#37;&#8211;100&#37;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;10&#44;11</span></a> and 87&#46;5&#37;&#8211;96&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> respectively&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Musculoskeletal manifestations were present in 88&#46;37&#37; of patients evaluated&#44; with a predominance of arthralgia &#40;75&#46;3&#37;&#41;&#46; Although arthralgia was clearly less common in the series of 26 patients published by Massa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#40;39&#37;&#41; and that of 15 patients published by Bocquet-Tr&#233;moreux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;6&#46;7&#37;&#41;&#44; the rates reported in the other series reviewed were similar to ours and in some cases even higher &#40;80&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#8211;100&#37;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9&#8211;11</span></a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Systemic corticosteroids were the most widely used drugs in the management of AF flares &#40;81&#37;&#41;&#44; followed by isotretinoin and systemic antibiotics&#59; 46&#46;2&#37; of patients were treated with a combination of systemic corticosteroids and isotretinoin&#46; Systemic corticosteroids were also the main drugs used in most of the larger series analyzed&#44; with rates of 88&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a> The rates for corticosteroids plus isotretinoin ranged between 50&#37; and 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;9</span></a> Oral antibiotics were administered to 23 &#40;95&#46;8&#37;&#41; of the 24 patients in the series by Karvonen&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> although this high usage may have been influenced by the date of the publication &#40;1993&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The current treatment of choice for AF is prednisone monotherapy at a dosage of 0&#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for at least 2 to 4 weeks&#44; followed by low doses of isotretinoin &#40;0&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Alternatives include topical or intralesional corticosteroids&#44; oral antibiotics &#40;although they do not tend to be very effective&#41;&#44; tumor necrosis factor inhibitors&#44; interleukin 1 antagonists&#44; and immunosuppressive agents such as azathioprine&#44; cyclosporine&#44; and methotrexate&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Colchicine&#44; apremilast&#44; dapsone&#44; and photodynamic therapy may also have beneficial effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> Pulsed dye laser therapy has shown moderate effectiveness&#44; but can cause adverse effects and pain&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Low-dose prednisone combined with isotretinoin is also recommended for the prevention of isotretinoin-associated AF in patients with severe inflammatory acne&#46; This initial treatment is followed by a gradual increase in isotretinoin over 3 to 5 months that should be managed according to tolerance&#46; In patients with an extremely high risk of AF&#44; prednisone monotherapy could be attempted for 2 weeks before initiation of isotretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Patients with AF can experience significant psychological morbidity due to body image concerns and in some cases may even develop body dysmorphic disorder &#40;BDD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In a pilot study of BDD and acne&#44; 8&#46;6&#37; of patients with mild acne and 14&#46;8&#37; of those with mild or moderate acne had BBD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> A follow-up multicenter study of 245 patients with mild acne showed similar results &#40;10&#46;6&#37; prevalence of BDD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Rates may be even higher in AF given the severity of lesions&#46; It is therefore advisable to screen for BDD in patients with acne and AF&#46; If a possible case is detected&#44; the patient should be referred to a mental health unit for diagnostic confirmation and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Acne&#44; regardless of its severity&#44; has also been linked to depressive syndromes and suicidal ideation&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Very few of the studies analyzed in our review evaluated quality of life impairment&#46; Just 2 of the 91 articles mentioned the psychological impact of AF&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> suggesting that it is underreported&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This review has some limitations&#46; It is based on case reports and series with heterogeneous reporting of clinical data&#46; We also placed no limit on the initial date for publications included&#46; This may have influenced the clinical variables described and treatments used&#46; The strength of this study lies in the number of patients evaluated &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>212&#41;&#44; as the largest series reviewed contain between 15 and 26 patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0155" class="elsevierStylePara elsevierViewall">Based on the findings of this narrative review&#44; AF is most common in adolescent boys with a previous history of acne vulgaris&#46; It appears suddenly&#44; over a period of days or weeks&#44; and isotretinoin has a key role as a trigger&#46; The face is affected most&#46; Hemorrhagic ulcers predominate&#44; although approximately 50&#37; of patients also experience scarring&#46; AF with systemic symptoms was the main subtype observed&#46; The most common manifestations are fever&#44; elevated ESR&#44; and leukocytosis&#46; Musculoskeletal involvement is also common&#44; in particular arthralgia with or without radiologic changes&#46; Systemic corticosteroids used alone or in combination with isotretinoin are the most widely used treatment&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Quality of life in patients with AF and the psychosocial impact of this disease are underreported&#46; More insights into these issues would help guide the development of action protocols by multidisciplinary teams&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">This work has not received any kind of funding&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Acne fulminans is a severe and rare form of inflammatory acne&#46; Lesion severity and subsequent scarring has a negative impact on the patient&#39;s quality of life&#46; We conducted a narrative review of the literature on acne fulminans based on a search for relevant English- and Spanish-language articles published in Medline&#46; We included case reports and case series&#46; The main aim was to describe the clinical and demographic characteristics of patients with acne fulminans&#46; A secondary aim was to determine whether quality of life was affected by the site or extent of lesions&#46; We reviewed 91 articles describing 212 cases of acne fulminans&#46; The mean age of the patients &#40;91&#46;94&#37; male&#41; was 16&#46;6 years&#46; A personal and family history of acne vulgaris was reported for 97&#46;63&#37; and 54&#46;90&#37; of patients&#44; respectively&#46; A trigger was identified in 44&#46;79&#37; of cases&#46; The main cause was pharmacologic &#40;96&#46;63&#37;&#41; and the main drug isotretinoin &#40;65&#46;28&#37;&#41;&#46; The sites most often affected were the face &#40;89&#46;31&#37;&#41;&#44; the posterior trunk &#40;77&#46;86&#37;&#41;&#44; and the anterior trunk &#40;74&#46;81&#37;&#41;&#46; The predominant disease subtype was acne fulminans with systemic symptoms &#40;59&#46;12&#37;&#41;&#44; which were mostly general &#40;97&#46;06&#37;&#41;&#46; Systemic corticosteroids were the most widely used treatment &#40;81&#46;03&#37;&#41;&#46; The impact of the disease on quality of life was reported for two patients&#46; In conclusion&#44; acne fulminans mainly affects the face and trunk of male adolescents with a history of acne vulgaris&#46; The main subtype was acne fulminans with systemic symptoms&#44; and most patients were treated with systemic corticosteroids&#46; The effect of acne fulminans on quality of life is under-reported&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El acn&#233; <span class="elsevierStyleItalic">fulminans</span> &#40;AF&#41; es una forma rara y grave de acn&#233; inflamatorio&#46; La intensidad de las lesiones cut&#225;neas y las cicatrices secundarias impactan negativamente en la calidad de vida&#46; Presentamos una revisi&#243;n narrativa de casos de AF publicados en Medline&#46; Se incluyeron art&#237;culos escritos en lengua castellana o inglesa&#44; que reportasen casos aislados o series de casos de AF&#44; de los que se recogieron variables cl&#237;nico-demogr&#225;ficas&#46; El objetivo principal de la revisi&#243;n fue describir las caracter&#237;sticas cl&#237;nico-demogr&#225;ficas del AF&#46; Secundariamente se pretendi&#243; determinar si la localizaci&#243;n o la extensi&#243;n lesional repercuten en la calidad de vida&#46; Se revisaron 212 casos de AF incluidos en 91 art&#237;culos &#40;edad media&#58; 16&#44;6 a&#241;os&#44; 91&#44;94&#37; varones&#41;&#59; 97&#44;63&#37; de los pacientes presentaron acn&#233; previo al brote de AF y 54&#44;90&#37; contaba con antecedentes familiares de acn&#233;&#46; En 44&#44;79&#37; existi&#243; un factor desencadenante de AF &#40;98&#44;63&#37; farmacol&#243;gico&#58; 65&#44;28&#37; isotretino&#237;na&#41;&#46; Las localizaciones m&#225;s habitualmente afectas fueron cara &#40;89&#44;31&#37;&#41;&#44; tronco posterior &#40;77&#44;86&#37;&#41; y anterior &#40;74&#44;81&#37;&#41;&#46; El subtipo predominante fue el AF asociado a s&#237;ntomas sist&#233;micos &#40;59&#44;12&#37;&#41;&#46; Entre los s&#237;ntomas sist&#233;micos destac&#243; la sintomatolog&#237;a general &#40;97&#44;06&#37;&#41;&#46; El tratamiento m&#225;s prevalente fue la corticoterapia sist&#233;mica &#40;81&#44;03&#37;&#41;&#46; La repercusi&#243;n del AF en la calidad de vida se report&#243; en dos pacientes&#46; Como conclusiones&#44; el AF predomina en los varones adolescentes con antecedentes de acn&#233; vulgar&#44; afectando fundamentalmente la cara y el tronco&#46; La forma m&#225;s frecuente es el AF con s&#237;ntomas sist&#233;micos&#46; Para su tratamiento&#44; los corticoides sist&#233;micos son los f&#225;rmacos m&#225;s frecuentemente empleados&#46; La repercusi&#243;n del AF en la calidad de vida est&#225; infrarreportada&#46;</p></span>"
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Comedones&#44; papules and pustules&#44; nodules and cysts&#44; erosions&#44; ulcerations&#44; and crusting in a patient with acne fulminans&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Flow chart showing inclusion and exclusion of articles&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Distribution of acne fulminans triggers &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>163&#41;&#46; <span class="elsevierStyleSup">a</span>Other&#58; incision and drainage&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Distribution of anatomic sites for acne fulminans lesions &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>131&#41;&#46; The sum of the bars is greater than 131 as some patients had lesions at more than 1 site&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1810
            "Ancho" => 2927
            "Tamanyo" => 190661
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Distribution of types of acne fulminans lesions &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>146&#41;&#46; The sum of the bars is greater than 146 as some patients had more than 1 type of lesion&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 2595
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            "Tamanyo" => 211948
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of subtypes of acne fulminans &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>137&#41;&#46; AF-SS indicates acne fulminans with systemic symptoms not induced by isotretinoin&#59; AF-WOSS&#44; acne fulminans without systemic symptoms not induced by isotretinoin&#59; IIAF-SS&#44; isotretinoin-induced acne fulminans with systemic symptoms&#59; IIAF-WOSS&#44; isotretinoin-induced acne fulminans without systemic symptoms&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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        "tabla" => array:2 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Manifestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enlarged lymph nodes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;23&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cutaneous manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;11&#46;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Digestive manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurologic-pyschiatric manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eye manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;97&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => "xTab3295026.png"
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Systemic manifestations were reported for 170&#47;193 patients &#40;88&#46;08&#37;&#41; in the reviewed literature&#44; but type of manifestation was specified in just 68 cases&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Systemic Manifestations Associated With Acne Fulminans &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&#41;&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
        ]
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      7 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; AF-SS&#44; acne fulminans with systemic symptoms not induced by isotretinoin&#59; AF-WOSS&#44; acne fulminans without systemic symptoms not induced by isotretinoin&#59; IIAF-SS&#44; isotretinoin-induced acne fulminans with systemic symptoms&#59; IIAF-WOSS&#44; isotretinoin-induced acne fulminans without systemic symptoms&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AF-SS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AF-WOSS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IIAF-SS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IIAF-WOSS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bocquet-Tr&#233;moureux et al&#46; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reunala et al&#46; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meinzer et al&#46; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Goldschimdt et al&#46; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Original Article
Acne Fulminans: A Narrative Review
Acné fulminans: revisión narrativa de la literatura
R. Gutiérrez-Meréa,b,
Corresponding author
raul.gutierrez.mere@sergas.es

Corresponding author.
, I. Tajesc, P. Diéguezc, D. Soto-Garcíaa,b, S. Martínez-Fernándeza,b, A. Batallaa,b
a Servicio de Dermatología, Complejo Hospitalario Universitario de Pontevedra, Área Sanitaria de Pontevedra y O Salnés, Pontevedra, Spain
b Grupo de Investigación DIPO, Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Pontevedra, Spain
c Escuela Universitaria de Enfermería, Diputación Provincial de Pontevedra, Universidad de Vigo, Vigo, Pontevedra, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acne fulminans &#40;AF&#41; is a severe and rare form of inflammatory acne that usually presents as an acute flare characterized by painful hemorrhagic pustules and ulcers with or without systemic manifestations &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Because of its intense inflammatory activity and scarring&#44; it can cause significantly impaired quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> AF is most common during adolescence&#44; a period in which perceived body image has a key role in the biopsychosocial sphere&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is therefore important to assess the impact of this disease on both psychological and social well-being&#46; The main aim of this study was to review the clinical and demographic characteristics of AF&#46; A secondary aim was to investigate whether quality of life is affected by the site or extent of lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Material and Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a narrative review of the literature on AF in patients with or without an associated autoinflammatory syndrome&#46; We included English- and Spanish-language case reports and series published in Medline-indexed journals&#46; We excluded articles written in a language other than Spanish or English&#44; articles other than case reports or series&#44; basic research studies&#44; and molecular studies&#44; even those that reported on a case of AF&#46; The search was conducted in PubMed &#40;Medline database&#41; using the search terms &#8220;acne&#8221; &#91;Medical Subject Headings&#93; AND &#8220;fulminans&#8221; and targeting all articles published up to January 7&#44; 2022&#46; No initial date limit was established&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The articles were selected by first screening the titles and abstracts of all articles retrieved by the search&#46; When it was not clear if the article was a case report or series&#44; the full article was accessed&#46; Articles not dealing with patients with AF were discarded after a full-text review&#46; All articles were reviewed independently by 2 authors &#40;IT and AB&#41;&#44; who then met in a face-to-face meeting to resolve any discrepancies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Information was collected on each article &#40;author&#44; title&#44; journal&#44; year of publication&#44; and number of patients&#41;&#44; demographics &#40;age&#44; sex&#41;&#44; clinical characteristics &#40;personal history of acne and duration&#44; family history of skin diseases&#44; time since onset of AF&#44; triggers&#44; lesion site&#44; type of lesions&#44; AF subtype&#44; systemic manifestations&#44; presence of fever&#44; erythrocyte sedimentation rate &#91;ESR&#93;&#44; leukocytosis&#44; musculoskeletal involvement&#44; radiologic changes&#44; involvement of other organs or systems&#44; and presence of an autoinflammatory syndrome&#41;&#44; treatments administered&#44; and impact of AF on quality of life&#46; Quality of life was assessed using information reported for each patient&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The data were entered into an Excel spreadsheet and analyzed in R &#40;version R i386 3&#46;4&#46;2&#41;&#46; We calculated the frequency distribution of qualitative variables and the mean &#40;SD&#41; of quantitative variables&#46; Associations between qualitative variables were analyzed using the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> or Fisher exact test&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">The search strategy yielded 169 articles published between 1977 and 2021&#46; The 2 researchers agreed on the initial selection of 79&#46;3&#37; of the articles&#59; 33&#47;169 articles presented discrepancies that required discussion&#46; After discussing the reasons for inclusion or exclusion in a face-to-face meeting&#44; the 2 researchers reached an agreement on all cases&#46; Ninety-one articles were finally included&#58; 74 case reports &#40;1 patient&#41; and 17 case series &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>2 patients&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The studies analyzed a total of 212 patients &#40;mean &#91;SD&#93; age&#44; 16&#46;6 &#91;3&#46;63&#93; years&#59; 91&#46;9&#37; male &#91;194&#47;211&#93;&#41;&#46; Overall&#44; 165&#47;169 patients &#40;97&#46;6&#37;&#41; had a past history of acne &#40;mean duration&#44; 19&#46;2 &#91;23&#46;4&#93; months&#41; and 14&#47;35 &#40;40&#37;&#41; had had severe acne&#46; A family history of skin disease was mentioned for 29&#47;51 patients &#40;56&#46;9&#37;&#41;&#46; Of these 29 patients&#44; 28 &#40;96&#46;6&#37;&#41; had had acne&#46; The most frequently affected family members were siblings &#40;57&#46;9&#37;&#44; 11&#47;19&#41; followed by parents &#40;42&#46;1&#37;&#44; 8&#47;19&#41;&#46; Mean time from onset of an AF flare to a physician visit was 4&#46;6 &#40;3&#46;9&#41; weeks&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The distribution of AF triggers is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; Drugs were mentioned as a trigger in 72&#47;73 patients &#40;98&#46;6&#37;&#41;&#46; Isotretinoin was the main drug involved &#40;65&#46;3&#37;&#44; 47&#47;72&#41;&#44; followed by tetracycline &#40;16&#46;7&#37;&#44; 12&#47;72&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The main sites for AF were the face &#40;89&#46;3&#37;&#44; 117&#47;131&#41;&#44; the posterior trunk &#40;77&#46;9&#37;&#44; 102&#47;131&#41;&#44; and the anterior trunk &#40;74&#46;8&#37;&#44; 79&#47;131&#41;&#46; The other sites are shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Hemorrhagic ulcers were the most common type of lesion &#40;58&#46;9&#37;&#44; 86&#47;146&#41;&#46; The prevalence of the other lesions ranged from 34&#46;9&#37; to 44&#46;5&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The main subtype of AF was AF with systemic symptoms not induced by isotretinoin &#40;AF-SS&#41; &#40;59&#46;1&#37;&#44; 81&#47;137&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Extracutaneous systemic manifestations were observed in 146&#47;169 patients &#40;86&#46;4&#37;&#41;&#46; The manifestations involved a single system in 43&#47;68 patients &#40;63&#46;2&#37;&#41;&#44; 2 systems in 22&#47;68 patients &#40;32&#46;4&#37;&#41;&#44; and 3 systems in 3&#47;68 patients &#40;4&#46;4&#37;&#41;&#46; The most common manifestations were general symptoms &#40;97&#46;1&#37;&#44; 66&#47;68&#41; followed by lymphadenopathy &#40;23&#46;5&#37;&#44; 16&#47;68&#41;&#46; The other organs and systems affected are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Overall&#44; 145&#47;180 patients &#40;80&#46;6&#37;&#41; had fever during the onset of AF&#44; 120&#47;126 &#40;95&#46;2&#37;&#41; had an elevated ESR &#40;mean&#44; 65&#46;4 &#91;28&#46;65&#93;<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#41;&#44; and 168&#47;186 &#40;90&#46;3&#37;&#41; had leukocytosis &#40;mean&#44; 15&#44;484&#46;90 &#91;3922&#46;38&#93;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span><span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Musculoskeletal involvement was mentioned for 152&#47;172 patients &#40;88&#46;4&#37;&#41;&#59; the main manifestation was arthralgia &#40;75&#46;3&#37;&#44; 143&#47;190&#41; followed by myalgia &#40;12&#46;2&#37;&#44; 17&#47;139&#41;&#46; Radiologic changes were observed in 73&#47;125 patients &#40;58&#37;&#41;&#46; Notable changes were increased uptake in scintigraphy &#40;31&#46;5&#37;&#44; 23&#47;73&#41; and osteolytic lesions &#40;27&#46;4&#37;&#44; 20&#47;73&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">An autoinflammatory syndrome was mentioned for 4&#47;146 patients &#40;2&#46;7&#37;&#41;&#58; 3 of the patients had SAPHO &#40;synovitis&#44; acne&#44; pustulosis&#44; hyperostosis&#44; and osteitis&#41; syndrome and 1 had PAPA &#40;pyogenic arthritis&#44; pyoderma gangrenosum&#44; and acne&#41; syndrome&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Systemic corticosteroids were the treatment of choice for 81&#37; of AF flares &#40;158&#47;195&#41;&#46; The next most common treatments were isotretinoin &#40;52&#46;3&#37;&#44; 102&#47;195&#41; and systemic antibiotics &#40;46&#46;2&#37;&#44; 90&#47;195&#41;&#46; A combination of systemic corticosteroids and isotretinoin was used in 90&#47;125 patients &#40;46&#46;2&#37;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Impact of AF on quality of life was reported for just 2 &#40;0&#46;9&#37;&#41; of the 212 patients analyzed&#46; Both patients had depression&#44; and a suicide attempt was mentioned for 1 of them&#46; Due to this very small subgroup&#44; we were unable to investigate the association between quality of life impairment and other variables&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The clinical and demographic characteristics of AF observed in this narrative review are largely consistent with findings to date&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our results confirm previous reports of a predominance of AF in adolescents and males&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> Practically all the patients &#40;97&#46;6&#37;&#41; in our review had a past history of acne&#44; demonstrating that absence of such a history is very rare&#46; Smaller series of 15&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 24&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> 25&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and 26<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> patients found that 100&#37; of patients with AF had a history of acne&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">An AF trigger was mentioned for 44&#46;8&#37; of patients analyzed in this review&#46; Drugs were the most common trigger &#40;98&#46;6&#37;&#41;&#44; with isotretinoin identified in 65&#46;3&#37; of cases&#46; Triggers described in the largest series to date vary considerably&#46; Bocquet-Tr&#233;moreux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> reported a pharmacologic trigger in 60&#37; of patients&#44; with isotretinoin responsible for all cases&#46; The rate in the series of 26 patients described by Massa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> was markedly lower&#44; at 12&#37;&#44; and none of the cases were associated with isotretinoin&#46; No triggers were observed for any of the 8 patients described by Goldschmidt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The most common sites for lesions in the studies reviewed in this series were the face &#40;89&#46;3&#37;&#41;&#44; the posterior trunk &#40;77&#46;9&#37;&#41;&#44; and the anterior trunk &#40;74&#46;8&#37;&#41;&#46; Other authors have reported a similar predominance of facial &#40;100&#37;&#41; and trunk &#40;87&#37;&#8211;88&#37;&#41; lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Hemorrhagic ulcers accounted for 58&#46;9&#37; of all AF lesions in our series&#46; The next most common lesions were nodules and cysts and papules and pustules&#46; Massa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported necrotic and ulcerating papules in all 26 patients analyzed&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Scarring was described in 5&#47;5 patients in the series by Meinzer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and in 0&#47;6 patients in that of Reunala et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In the studies in our review&#44; scarring was reported for 43&#46;8&#37; of patients&#46; These findings must be interpreted with caution&#44; as it can take time for residual scarring to develop after resolution of an AF flare&#46; Karvonen<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> indicated that while 82&#37; of patients no longer had active lesions after several years&#44; they did have residual scarring&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The pooled analysis of AF cases in our review showed that AF-SS was the most common subtype &#40;59&#46;1&#37;&#41;&#44; followed by isotretinoin-induced AF with systemic symptoms &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Other series show a different distribution&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8&#8211;11</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Overall&#44; 86&#46;4&#37; of patients had extracutaneous manifestations&#44; which were general &#40;nonspecific&#41; in 97&#46;1&#37; of cases&#46; Very few series of 5 or more patients in our review specified type of systemic manifestations&#46; Seukeran and Cunliffe<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported loss of appetite in 17&#47;25 patients &#40;68&#37;&#41; and weight loss in 9&#47;25 &#40;36&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> All six patients examined by Reunala et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> had general malaise&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Fever was present in 80&#46;6&#37; of the patients reviewed&#46; Other series have reported rates ranging from 92&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> to 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Just 9 &#40;35&#37;&#41; of the 26 patients described by Massa et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> however&#44; had fever&#46; Our findings for elevated ESR and peripheral leukocytosis are consistent with rates in the literature of 92&#37;&#8211;100&#37;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;10&#44;11</span></a> and 87&#46;5&#37;&#8211;96&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> respectively&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Musculoskeletal manifestations were present in 88&#46;37&#37; of patients evaluated&#44; with a predominance of arthralgia &#40;75&#46;3&#37;&#41;&#46; Although arthralgia was clearly less common in the series of 26 patients published by Massa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#40;39&#37;&#41; and that of 15 patients published by Bocquet-Tr&#233;moreux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;6&#46;7&#37;&#41;&#44; the rates reported in the other series reviewed were similar to ours and in some cases even higher &#40;80&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#8211;100&#37;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9&#8211;11</span></a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Systemic corticosteroids were the most widely used drugs in the management of AF flares &#40;81&#37;&#41;&#44; followed by isotretinoin and systemic antibiotics&#59; 46&#46;2&#37; of patients were treated with a combination of systemic corticosteroids and isotretinoin&#46; Systemic corticosteroids were also the main drugs used in most of the larger series analyzed&#44; with rates of 88&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a> The rates for corticosteroids plus isotretinoin ranged between 50&#37; and 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;9</span></a> Oral antibiotics were administered to 23 &#40;95&#46;8&#37;&#41; of the 24 patients in the series by Karvonen&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> although this high usage may have been influenced by the date of the publication &#40;1993&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The current treatment of choice for AF is prednisone monotherapy at a dosage of 0&#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for at least 2 to 4 weeks&#44; followed by low doses of isotretinoin &#40;0&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Alternatives include topical or intralesional corticosteroids&#44; oral antibiotics &#40;although they do not tend to be very effective&#41;&#44; tumor necrosis factor inhibitors&#44; interleukin 1 antagonists&#44; and immunosuppressive agents such as azathioprine&#44; cyclosporine&#44; and methotrexate&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Colchicine&#44; apremilast&#44; dapsone&#44; and photodynamic therapy may also have beneficial effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> Pulsed dye laser therapy has shown moderate effectiveness&#44; but can cause adverse effects and pain&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Low-dose prednisone combined with isotretinoin is also recommended for the prevention of isotretinoin-associated AF in patients with severe inflammatory acne&#46; This initial treatment is followed by a gradual increase in isotretinoin over 3 to 5 months that should be managed according to tolerance&#46; In patients with an extremely high risk of AF&#44; prednisone monotherapy could be attempted for 2 weeks before initiation of isotretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Patients with AF can experience significant psychological morbidity due to body image concerns and in some cases may even develop body dysmorphic disorder &#40;BDD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In a pilot study of BDD and acne&#44; 8&#46;6&#37; of patients with mild acne and 14&#46;8&#37; of those with mild or moderate acne had BBD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> A follow-up multicenter study of 245 patients with mild acne showed similar results &#40;10&#46;6&#37; prevalence of BDD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Rates may be even higher in AF given the severity of lesions&#46; It is therefore advisable to screen for BDD in patients with acne and AF&#46; If a possible case is detected&#44; the patient should be referred to a mental health unit for diagnostic confirmation and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Acne&#44; regardless of its severity&#44; has also been linked to depressive syndromes and suicidal ideation&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Very few of the studies analyzed in our review evaluated quality of life impairment&#46; Just 2 of the 91 articles mentioned the psychological impact of AF&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> suggesting that it is underreported&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This review has some limitations&#46; It is based on case reports and series with heterogeneous reporting of clinical data&#46; We also placed no limit on the initial date for publications included&#46; This may have influenced the clinical variables described and treatments used&#46; The strength of this study lies in the number of patients evaluated &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>212&#41;&#44; as the largest series reviewed contain between 15 and 26 patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0155" class="elsevierStylePara elsevierViewall">Based on the findings of this narrative review&#44; AF is most common in adolescent boys with a previous history of acne vulgaris&#46; It appears suddenly&#44; over a period of days or weeks&#44; and isotretinoin has a key role as a trigger&#46; The face is affected most&#46; Hemorrhagic ulcers predominate&#44; although approximately 50&#37; of patients also experience scarring&#46; AF with systemic symptoms was the main subtype observed&#46; The most common manifestations are fever&#44; elevated ESR&#44; and leukocytosis&#46; Musculoskeletal involvement is also common&#44; in particular arthralgia with or without radiologic changes&#46; Systemic corticosteroids used alone or in combination with isotretinoin are the most widely used treatment&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Quality of life in patients with AF and the psychosocial impact of this disease are underreported&#46; More insights into these issues would help guide the development of action protocols by multidisciplinary teams&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">This work has not received any kind of funding&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Material and Methods"
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          "titulo" => "Results"
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          "titulo" => "Conclusions"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2023-04-10"
    "fechaAceptado" => "2023-05-06"
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          "clase" => "keyword"
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            0 => "Acne"
            1 => "Acne fulminans"
            2 => "Quality of life"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Acn&#233;"
            1 => "Acn&#233; <span class="elsevierStyleItalic">fulminans</span>"
            2 => "Calidad de vida"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Acne fulminans is a severe and rare form of inflammatory acne&#46; Lesion severity and subsequent scarring has a negative impact on the patient&#39;s quality of life&#46; We conducted a narrative review of the literature on acne fulminans based on a search for relevant English- and Spanish-language articles published in Medline&#46; We included case reports and case series&#46; The main aim was to describe the clinical and demographic characteristics of patients with acne fulminans&#46; A secondary aim was to determine whether quality of life was affected by the site or extent of lesions&#46; We reviewed 91 articles describing 212 cases of acne fulminans&#46; The mean age of the patients &#40;91&#46;94&#37; male&#41; was 16&#46;6 years&#46; A personal and family history of acne vulgaris was reported for 97&#46;63&#37; and 54&#46;90&#37; of patients&#44; respectively&#46; A trigger was identified in 44&#46;79&#37; of cases&#46; The main cause was pharmacologic &#40;96&#46;63&#37;&#41; and the main drug isotretinoin &#40;65&#46;28&#37;&#41;&#46; The sites most often affected were the face &#40;89&#46;31&#37;&#41;&#44; the posterior trunk &#40;77&#46;86&#37;&#41;&#44; and the anterior trunk &#40;74&#46;81&#37;&#41;&#46; The predominant disease subtype was acne fulminans with systemic symptoms &#40;59&#46;12&#37;&#41;&#44; which were mostly general &#40;97&#46;06&#37;&#41;&#46; Systemic corticosteroids were the most widely used treatment &#40;81&#46;03&#37;&#41;&#46; The impact of the disease on quality of life was reported for two patients&#46; In conclusion&#44; acne fulminans mainly affects the face and trunk of male adolescents with a history of acne vulgaris&#46; The main subtype was acne fulminans with systemic symptoms&#44; and most patients were treated with systemic corticosteroids&#46; The effect of acne fulminans on quality of life is under-reported&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El acn&#233; <span class="elsevierStyleItalic">fulminans</span> &#40;AF&#41; es una forma rara y grave de acn&#233; inflamatorio&#46; La intensidad de las lesiones cut&#225;neas y las cicatrices secundarias impactan negativamente en la calidad de vida&#46; Presentamos una revisi&#243;n narrativa de casos de AF publicados en Medline&#46; Se incluyeron art&#237;culos escritos en lengua castellana o inglesa&#44; que reportasen casos aislados o series de casos de AF&#44; de los que se recogieron variables cl&#237;nico-demogr&#225;ficas&#46; El objetivo principal de la revisi&#243;n fue describir las caracter&#237;sticas cl&#237;nico-demogr&#225;ficas del AF&#46; Secundariamente se pretendi&#243; determinar si la localizaci&#243;n o la extensi&#243;n lesional repercuten en la calidad de vida&#46; Se revisaron 212 casos de AF incluidos en 91 art&#237;culos &#40;edad media&#58; 16&#44;6 a&#241;os&#44; 91&#44;94&#37; varones&#41;&#59; 97&#44;63&#37; de los pacientes presentaron acn&#233; previo al brote de AF y 54&#44;90&#37; contaba con antecedentes familiares de acn&#233;&#46; En 44&#44;79&#37; existi&#243; un factor desencadenante de AF &#40;98&#44;63&#37; farmacol&#243;gico&#58; 65&#44;28&#37; isotretino&#237;na&#41;&#46; Las localizaciones m&#225;s habitualmente afectas fueron cara &#40;89&#44;31&#37;&#41;&#44; tronco posterior &#40;77&#44;86&#37;&#41; y anterior &#40;74&#44;81&#37;&#41;&#46; El subtipo predominante fue el AF asociado a s&#237;ntomas sist&#233;micos &#40;59&#44;12&#37;&#41;&#46; Entre los s&#237;ntomas sist&#233;micos destac&#243; la sintomatolog&#237;a general &#40;97&#44;06&#37;&#41;&#46; El tratamiento m&#225;s prevalente fue la corticoterapia sist&#233;mica &#40;81&#44;03&#37;&#41;&#46; La repercusi&#243;n del AF en la calidad de vida se report&#243; en dos pacientes&#46; Como conclusiones&#44; el AF predomina en los varones adolescentes con antecedentes de acn&#233; vulgar&#44; afectando fundamentalmente la cara y el tronco&#46; La forma m&#225;s frecuente es el AF con s&#237;ntomas sist&#233;micos&#46; Para su tratamiento&#44; los corticoides sist&#233;micos son los f&#225;rmacos m&#225;s frecuentemente empleados&#46; La repercusi&#243;n del AF en la calidad de vida est&#225; infrarreportada&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Comedones&#44; papules and pustules&#44; nodules and cysts&#44; erosions&#44; ulcerations&#44; and crusting in a patient with acne fulminans&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Distribution of acne fulminans triggers &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>163&#41;&#46; <span class="elsevierStyleSup">a</span>Other&#58; incision and drainage&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Distribution of anatomic sites for acne fulminans lesions &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>131&#41;&#46; The sum of the bars is greater than 131 as some patients had lesions at more than 1 site&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Distribution of types of acne fulminans lesions &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>146&#41;&#46; The sum of the bars is greater than 146 as some patients had more than 1 type of lesion&#46;</p>"
        ]
      ]
      5 => array:7 [
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        "etiqueta" => "Figure 6"
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        "mostrarFloat" => true
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        "figura" => array:1 [
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            "imagen" => "gr6.jpeg"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of subtypes of acne fulminans &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>137&#41;&#46; AF-SS indicates acne fulminans with systemic symptoms not induced by isotretinoin&#59; AF-WOSS&#44; acne fulminans without systemic symptoms not induced by isotretinoin&#59; IIAF-SS&#44; isotretinoin-induced acne fulminans with systemic symptoms&#59; IIAF-WOSS&#44; isotretinoin-induced acne fulminans without systemic symptoms&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Manifestation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41; of patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Enlarged lymph nodes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">16 &#40;23&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Cutaneous manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;11&#46;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Digestive manifestations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Neurologic-pyschiatric manifestations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;4&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Eye manifestations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">General symptoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">66 &#40;97&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Systemic manifestations were reported for 170&#47;193 patients &#40;88&#46;08&#37;&#41; in the reviewed literature&#44; but type of manifestation was specified in just 68 cases&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Systemic Manifestations Associated With Acne Fulminans &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&#41;&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
        ]
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        "etiqueta" => "Table 2"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; AF-SS&#44; acne fulminans with systemic symptoms not induced by isotretinoin&#59; AF-WOSS&#44; acne fulminans without systemic symptoms not induced by isotretinoin&#59; IIAF-SS&#44; isotretinoin-induced acne fulminans with systemic symptoms&#59; IIAF-WOSS&#44; isotretinoin-induced acne fulminans without systemic symptoms&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Bocquet-Tr&#233;moureux et al&#46; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Goldschimdt et al&#46; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&nbsp;\t\t\t\t\t\t\n
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