Acne fulminans in a patient with suspected bigorexia

Introduction

Acne vulgaris is one of the most common skin diseases. It occurs in 80–100% of the population. This skin disorder significantly decreases patients’ quality of life [1]. The pathogenesis of acne is highly complex. The main pathogenetic factors are connected to abnormal keratosis of hair follicle ostia, presence of the saprophytic bacterium Propionibacterium acnes and an incorrect response of the immune system of the skin. The excessive activity of sebaceous glands controlled by androgens – testosterone and dihydrotestosterone – is another key factor that contributes to the development of the disorder, which does not occur in eunuchs [2–5].
Acute febrile ulcerative acne (acne fulminans) is a form of concentrated acne, which tends to form numerous abscesses and significant scarring. It occurs mainly in young men. Accompanying symptoms may be fever, weight loss, muscle and joint pain (the result of bone marrow inflammation affecting the sternoclavicular joint) and/or erythema nodosum. In such cases, laboratory tests show elevated erythrocyte sedimentation rate erythrocyte sedimentation rate (ESR), leukocytosis, abnormalities in liver values and proteinuria [4, 6]. Bodybuilding acne is a variant of acne fulminans caused by the use of hormonal products in order to increase muscle mass and improve fitness [6].
The word dysmorphobia (body dysmorphic disorder – BDD) is derived from the Greek word “dysmorphia”, meaning ugliness, especially of the face. The term was introduced in 1886 by Morselli, who defined it as a subjective feeling of ugliness, which the patient considers to be a serious problem, while the patient’s appearance is not abnormal or the changes in appearance are exaggerated by the patient. A common symptom of this disorder is frequent inspections of one’s appearance, e.g. by looking into the mirror [7–12]. People suffering from BDD want to improve their appearance and are convinced that the problem lies in an actual defect rather than a subjective distorted perception of their body [9]. According to the ICD-10 classification, BDD is considered a mental disorder under code F45.2. The severity of symptoms may fluctuate from obsessive to delusional and back [7]. A person suffering from BDD may also be concerned with their body structure. About 80% of BDD patients have suicidal thoughts and as many as 15–28% attempt suicide [7, 9].
One variety of BDD is bigorexia (muscle dysmorphia) – often referred to as reverse anorexia or Adonis complex. The term was coined in 1997 and the first researcher to describe bigorexia was Harrison Pope. A patient suffering from bigorexia is obsessively preoccupied with building muscle mass and feels that their body will never be sufficiently muscled.
A person with muscle dysmorphobia spends a lot of time training their strength, repeatedly takes muscle measurements, follows various high-protein diets and/or even uses anabolic steroids. The patient is ashamed to expose their body (e.g. on a beach or at a pool) as it makes them feel embarrassed and dissatisfied. It is estimated that about 10% of gym customers suffer from bigorexia [7, 9, 13–15]. Being excessively preoccupied with one’s body build leads to dysfunction in the patient’s family as well as social and professional life [9].
When treating such patients, behavioural psychotherapy and pharmacotherapy are used. Sometimes it is necessary to also include antidepressants [7, 15].

Objective

This article presents a psychodermatological case of a young man with suspected bigorexia that most likely led to the patient’s use of anabolic drugs, consequently resulting in the development of acne fulminans in the patient.

Case report

A 21-year-old physical worker reported to the Department of Dermatology in Opole with suspected acne fulminans. Skin lesions had appeared about 2 months after the patient started to use anabolic agents in combination with intensive exercises at the gym in order to develop muscle mass. Initially, the patient had not agreed to be referred to a hospital, which he explained, among other things, by the need to continue taking hormones. Due to significant testosterone level abnormalities (exceeding the normal level by about a dozen-fold) and absence of results of tests necessary to undertake isotretinoin treatment, lymecycline at a dose of 2 × 300 mg/day was prescribed on an outpatient basis. Afterwards, the patient decided to undergo hospital treatment.
The patient was admitted in a good general condition. He reported severe pain in the area of skin lesions and bone and muscle pains, mainly of the shoulder band and weakness. The interview with the patient showed that during puberty, the patient exhibited acne lesions of mild intensity, which did not require therapy.
Physical examination revealed enlarged musculature, slight mobility restriction in the thoracic spine area and a minor forward inclination of the body and arms. Apart from that, no abnormalities were found. Skin lesions occurred in the facial, neck and torso areas – mainly in the upper and middle parts. There were numerous lesions in the form of inflammatory cysts, pustules and inflammatory nodules with a tendency to form necrotic masses covered with haemorrhagic crusts (figs. 1, 2). During hospitalisation, additional tests were carried out; they showed elevated ESR of 35 mm, leukocytosis over 16,000/UI in blood, a slightly elevated level of platelets (353,000/UI), elevated level of hormones, LH 9.9 mlU/ml, SHGB 61 nmol/l and PSA 2.01 ng/ml (at discharge there was a rising tendency of 2.28 ng/ml) and the presence of protein in urine (352.5 mg/l). Testosterone level was within normal limits, at 6.14 ng/ml. X-rays of sternoclavicular joints did not reveal any irregularities. The patient consulted an endocrinologist, who recommended getting off hormonal drugs. The psychologist assessed the patient as follows: “The patient is fully conscious, his allo – and autopsychic orientation is correct.
The emotional state of the patient is normal. He admits that he devotes all his time to exercising at the gym. He took anabolic agents because he no longer had the strength to exercise and did not see any results in his body. The patient does not see anything wrong with using these drugs. He does not intend to give them up and he claims that in a few years’ time, he will start to take them again”. In addition, the DLQI questionnaire was evaluated with a score of 15 points. In the clinic, the patient was prescribed isotretinoin treatment at a dose of 60 mg/day and prednisone at a dose of 30 mg/day. Due to pain the patient was prescribed ketoprofen p.o. at a dose of 100 mg/day. Partial improvement in clinical condition was achieved. The patient was discharged in good general condition. Outpatient visit to an urologist was recommended due to prostate hypertrophy revealed in the ultrasound and psychiatric consultations were advised. The patient received psychiatric consultation 6 months after the beginning of the dermatological treatment in a significantly better clinical condition compared to his state upon admission to the hospital. The psychiatrist stated that it is difficult to make a clear diagnosis of bigorexia after a single visit, although the interview does indicate the abovementioned diagnosis. The doctor recommended further monitoring and observation of the patient; however, the patient did not show up at the following planned appointments.

Discussion

The patient described above is a complex case from the field of psychodermatology, a discipline that deals with the relationship between psychiatric, psychological and dermatological symptomatology. Estimates indicate that up to 60% of patients with skin diseases have various disorders: depressive, anxious and other [7].
Body dysmorphic disorder in the form of bigorexia, i.e. continuous lack of acceptance of the structure of one’s body, induced the patient to take anabolic drugs. The consequence was acne fulminans. Skin disfigurement put an additional burden on the patient physically (intensified purulent skin lesions with scarring), emotionally and psychologically (further decrease in self-acceptance, isolation, feeling of helplessness – the patient’s quality of life was lowered in virtually all its aspects), including avoiding social interactions and intimate contacts [7, 9]. The dysmorphic disorder of the patient shifted towards acne, which became a leading problem involving stigmatisation. His acne problem started to absorb the patient more than bigorexia. It is highly worrisome that the patient intends to take anabolics again in the future and that he is not concerned about the consequences of this decision.
Body dysmorphic disorder is a disorder which is relatively common in dermatology and psychiatry, yet it is underdiagnosed. The psychological consequences of BDD in the form of embarrassment and anxiety may influence the social and professional life of the people who suffer from it.
The data show that 8–14% of dermatological patients suffer from BDD. Among the patients of plastic (aesthetic) surgeons, this percentage reaches up to 53%, while the prevalence rate in the general population is about 0.7–2.4% [16].
Introduction of a BDD questionnaire onto the Polish market, through the validation of an appropriate scale, may improve the rates of properly diagnosed BDD.
To sum up, the dermatologist is often the first doctor whom a patient with BDD symptoms visits. It is advisable to screen dermatological patients for BDD, anxiety and depression disorders.

Conclusions

The key to the therapeutic success of the patient described above is the close cooperation of the dermatologist, psychiatrist and the patient, whose attitude towards the problem of taking androgens is not rational. It is also important to draw the attention of teachers, gym owners and the general media to the problem of bigorexia and the harmfulness of anabolic use. An unnaturally muscular body in men should not be promoted.

Conflict of interest

The authors declare no conflict of interest.

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