Ms. Austin is a healthy 21 year-old woman, who appears very anxious in the waiting room. She has a 2-year history of acne vulgaris unresponsive to herbal remedies, topical retinoid agents, and combined topical antibiotic/benzoyl peroxide preparations. She reports that within the past 3 months she has suffered significant discomfort and public embarrassment from the inflamed deep cysts. She is here to get a second opinion about how to improve her acne, stating that her general practitioner has done everything in his power to help her.

Ms. Austin’s past medical history is unremarkable, and she is currently not taking any medications. Physical exam reveals mixed severe inflammatory and moderate nodulocystic acne. Surprisingly, it appears that she has never been given oral antibiotics or oral retinoids. When you broach the subject of trying an oral antibiotic agent in combination with her topical regimen, her strong rejection of your recommendation takes you aback: “Is this a pill, Doctor? I don’t want to take any pills because they are not good for my body. I have heard many horror stories about people having bad side effects while taking pills. These cysts are terrible, but they don’t kill me – I would rather leave them alone than taking pills to make them disappear.”