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Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome, is a relatively rare disorder. We report an adolescence patient with refractory SAPHO syndrome and acne fulminans, successfully treated with isotretinoin and etanercept. A 17-years-old man admitted with the complaints of fever, severe ulcerative acneiform lesions and inability to walk due to hip pain for the last 10 days while undergoing isotretinoin treatment for acne conglobata. There was severe acne conglabata history for about 3 months. Skin ulcerations and hip pain have developed at the 15 day of the 30 mg/day oral isotretinoin treatment. His family history was unremarkable for acne conglobata or joint disease. Dermatological examination revealed numerous inflammatory nodules, comedones, in addition to painful ulcers with overhanging borders surrounding exudative necrotic plaques on back, chest, gluteal and inguinal areas (Figure 1 a,b). The informed consent form was obtained for photographs. On physical examination, bilaterally hip joint movements and lumbar flexion were painful and limited. Laboratory evaluations demonstrated increased level of C-reactive protein (7.5 ng/mL), and leukocytosis (26.5 Ku/L). Blood and urine cultures showed no bacterial growth. Serum immunoglobulin levels were within normal ranges, and rapid plasma reagin test, human leukocyte antigen B27, rheumatoid factor, and anti-nuclear antibody were all negative. His left sternoclavicular and sternocostal joints were painful with palpation. Sacroiliac compression and distraction tests were positive. Bilateral shoulder and hip joints were not limited but painful. His sacroiliac magnetic resonance imaging showed bilateral sacroiliitis (Figure 2a, b). The whole body bone scintigraphy showed intense uptake at bilateral sacroiliac and sternoclavicular joints revealing bilateral sacroiliitis and sternoclavicular joint arthritis. Initially he was treated with non-steroid anti-inflammatory drugs (NSAIDs), ampicillin/sulbactam and clindamycin for 2 weeks. The symptoms did not resolve by the cessation of isotretinoin and symptomatic treatment. He was treated with 40 mg/day methylprednisolone tapered 6 weeks. While reducing steroid

SAPHO syndrome associated with acne fulminans in an adolescent patient