LAUSR

A 26-year-old male bodybuilder presented with a threemonth history of severe acne on his face and upper trunk. He reported receiving daily injection of nandrolone decanoate (250 mg/mL) and trenbolone enanthate (200 mg/mL) for one month. He then switched to trenbolone at 200 mg/mL and drostanolone proportionate (100 mg/mL) for two months, along with daily injections of testosterone (250 mg) and somatropin (4 IU) for three months. The patient stopped all medications one week prior to consultation. Clinical examination revealed multiple nodulocystic lesions on the face and upper trunk (figure 1A, B). The diagnosis of acne conglobata was made. He was considered to be at high risk of acne fulminans (AF), therefore, combination therapy of isotretinoin (0.1 mg/kg/d) with systemic steroids (prednisolone at 0.5 mg/kg/d) was initiated. Three weeks later, he developed multiple painful reddish papulonodular and ulcerated lesions with haemorrhagic crusts on his face, chest, and back. Arthralgias and fever (39◦C) were noted. Abnormal laboratory findings included elevated erythrocyte sedimentation rate (73 mm/hr) and leukocytosis (16.2 × 109/L) with neutrophilia (83.8%). Microbial swabs showed commensal Staphylococcus species. Testosterone and insulin levels were unknown. AF was diagnosed and the patient was admitted to hospital without discontinuing isotretinoin. Intravenous hydrocortisone, at 100 mg three times/day, was started. The cutaneous lesions and the laboratory abnormalities improved. One week later, after the fever subsided, the patient was discharged on oral prednisone at 40 mg (0.5 mg/kg/d). The patient continued taking isotretinoin at 10 mg and prednisolone at 40 mg for four weeks.