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Acne fulminans is a severe form of cystic acne with ulcerating lesions associated with systemic symptoms such as fever, myalgias, arthralgias, and hepatosplenomegaly. Pyoderma faciale is an inflammatory cystic acneiform eruption on the central face of young women. Severe scarring can result without treatment. Dissecting cellulitis of the scalp and neck is an inflammatory scarring process seen mostly in young black males. Acne keloidalis nuchae is a perifollicular inflammatory process of the scalp. These diagnoses are made clinically.

Acute treatment of acne fulminans and pyoderma faciale includes systemic corticosteroids (prednisone 40 to 60 milligrams daily) and continuation of isotretinoin if already on it. Dissecting cellulitis of the scalp is treated with 5% to 10% benzoyl peroxide washes and oral doxycycline or minocycline. Acne keloidalis nuchae can be treated with topical clindamycin, topical corticosteroids (fluocinonide), and oral doxycycline or minocycline. Refer to a dermatologist for further management, including consideration of initiation of isotretinoin.

Herpes zoster results from activation of latent varicella zoster virus.

Clinical Features

Pain or dysesthesia in the involved dermatome begins several days before lesions emerge. Erythematous papules develop first, progress to vesicular clusters, which crust after about a week. Lesions of the ophthalmic branch of the trigeminal nerve, especially if accompanied by lesions on the nose, are concerning for ophthalmic involvement (keratitis, ulceration) (Fig. 155-1). A thorough eye exam, including slit lamp exam, should be performed (see Chapter 149 “Ocular Emergencies”). Generalized eruptions may occur in immunocompromised patients.

Figure 155-1.

A. Herpes zoster in trigeminal nerve distribution. Note lesion on the tip of the nose, which suggests nasociliary branch involvement. B. Dermatomes of the head and neck. cev. = cervical; Gr. = greater; N. = nerve; Sm. = smaller. (A reproduced with permission from Fleischer A Jr, Feldman S, McConnell C, et al: Emergency Dermatology: A. Rapid Treatment Guide. New York, McGraw-Hill, 2002, p. 157. B. Reproduced with permission from Wolff K, Johnson R, Suurmond R: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005.)

Diagnosis and Differential

The differential diagnosis includes herpes simplex, impetigo, and contact dermatitis. The key to diagnosis in patients is pronounced pain at the site and a unilateral distribution. A Tzanck prep and viral PCR can confirm the clinical diagnosis.

Emergency Department Care and Disposition

  1. Antivirals started in the first 72 hours of presentation shortens healing time, decreases formation of new lesions, and helps prevent postherapeutic neuralgia. Antiviral choices include acyclovir 800 milligrams PO 5 times per day for 7 to 10 days or valacyclovir 1000 milligrams PO three times a day for 7 days. Patient with HIV/AIDS should take ...

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