Resolution of nodulocystic acne with oral dapsone

A 14-year-old Caucasian boy showed a clinical picture of nodulocystic acne. His past medical history was negative for important dermatosis and he had no comorbidities. Because of unresponsiveness to oral tetracycline and topical adapalene/benzoyl peroxide, the patient started 30 mg/ day of oral isotretinoin. After 2 months, no improvement of lesions was evident. Furthermore, the patient showed painful papules, pustules, and crusts on the face and forehead (Figure 1). No fever, weight loss, myalgia, arthralgia, or other systemic symptoms were present and laboratory routine tests were within the normal range. The patient started methylprednisolone 25 mg/day, reducing oral isotretinoin to 20 mg/day. Because of the absence of lesions improvement, oral isotretinoin was stopped and oral dapsone 300 mg/day was introduced, gradually tapering methylprednisolone. After 5 months, a clear improvement of lesions was observed. Then, dapsone was stopped and the patient started 0.05% tretinoin cream daily, 10% glycolic acid cream every other day, leading to a complete remission of the clinical picture (Figure 2). Although acne is an extremely common disease, it is often difficult to treat severe acne, like the nodulocystic and the conglobate form, not responsive to antibiotic drugs and adapalene/benzoyl peroxide. Oral isotretinoin is an extremely useful drug in severe acne recalcitrant to topical therapy and oral antibiotic drugs (Zouboulis & Bettoli, 2015). However, its teratogenicity and side effects, including rhabdomyolysis, facial hirsutism, cheilitis, elevation in white blood cells count, hepatic and lipid panels, limit the use of this drugs in some categories of patients, especially in female population (Lee et al., 2015; Zouboulis & Bettoli, 2015). In addition, isotretinoin could determine a worsening of acne lesions, up to an extremely serious form of acne known as acne fulminans, characterized by systemic symptoms, including fever, weight loss, myalgia, and arthralgia (Zaba, Schwartz, Jarmuda, CzarneckaOperacz, & Silny, 2011). Dapsone also could be an adequate drug to control severe acne (Zouboulis & Bettoli, 2015), as reported in our case. Topical dapsone 5% gel has been reported as effective in the literature (Zouboulis & Bettoli, 2015). By contrast, there are only few reports on using oral dapsone as therapy for severe acne (Wakabayashi, Fujii, Fujimoto, & Tanaka, 2013), probably because of its well-known systemic side effects, including hemolytic anemia and methemoglobinemia. However, it is possible to prevent these side effects testing glucose-6-phosphate dehydrogenase levels before dapsone administration. In addition, it is needed to follow-up patients performing regular routine laboratory tests and clinical examinations over the time (Wakabayashi et al., 2013). Although dapsone is widely known for its pivotal role in the therapy of leprosy, it has also been used in several skin diseases because of its anti-inflammatory properties (Predivelle, Logan, & Russell-Jones, 1988). Based on our report and papers in the literature (Predivelle et al., 1998; Wakabayashi et al., 2013; Zouboulis & Bettoli, 2015), it is possible to highlight that systemic dapsone could be an effective and safe alternative to isotretinoin in severe acne recalcitrant to other systemic drugs. Nevertheless, it is mandatory to close monitor patients, because of the possible systemic side effects due to dapsone therapy.