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Objective: Acne fulminans is an uncommon form of ulcerative acne with acute onset. It usually affects adolescent boys who have associated musculoskeletal pain and septic fever. Osteolytic bone lesions have been reported in these patients. Severe cystic acne occurs almost equally in both sexes, but it has a less dramatic clinical course than acne fulminans and rarely causes ulcerative skin lesions and systemic symptoms. In this study we investigated the imaging features of bone lesions associated with acne fulminans and determined if patients with severe cystic acne have similar bone lesions., Subjects and Methods: From 1970 through 1991, 24 patients with acne fulminans were treated in the dermatologic departments of Finnish hospitals. Radiologic (plain radiographs or conventional tomograms) or scintigraphic data were available for 21 patients and analyzed retrospectively. For comparison, 20 consecutive patients with severe cystic acne were examined prospectively with scintigraphy., Results: Ten patients (48%) with acne fulminans had lytic bone lesions on the radiographs, and the bone scans showed increased uptake in 14 patients (67%). Destructive lesions resembling osteomyelitis were seen in seven patients. The bones of the anterior chest wall were predominantly involved: sternum in four patients, clavicle in three patients, and acromion scapulae in one patient. Sternoclavicular hyperostosis was seen in six patients. Four patients had small lytic lesions in the epiphyseal growth plate or a periosteal reaction. Follow-up was performed in eight patients with acne fulminans and in seven revealed either normal findings or sclerosis and hyperostosis in the previously affected areas of the sternum and clavicles. Slightly increased uptake of radionuclide, usually in the sternum or around the sternoclavicular joints, was seen in nine patients with severe cystic acne, but these findings were regarded as normal and radiographs were not obtained., Conclusion: Lytic lesions in the bones of the anterior chest wall and in the epiphyseal growth plates are common in patients with acne fulminans, but do not seem to occur in patients with severe cystic acne. The prognosis of bone disease associated with acne fulminans appears to be good, and the chronic sequelae, if any, are mild sclerosis and hyperostosis of the affected bones. Acne fulminans should be added to the list of dermatoses associated with bone lesions detectable by radiologic and scintigraphic methods.