Although love looks not with the eyes but with the mind, as Shakespeare reminds us, there is a redness of the cheek that is not as kind as a simple blush. So may the outward shows be least themselves, he also says. The world is still deceived with ornament.
Acne arrives at the wrong time of life; it usually declares itself around the same time a teenager is trying to establish her identity; trying to acquire independence; experimenting with relationships outside the family. It is a time of uncertainty when self-esteem and confidence may be suspended, like the Sword of Damocles, on that single hair of outward appearance.
Acne is nothing new; it has probably been around as long as there has been skin with hair follicles to get blocked. Oil from glands is one of the culprits and these are more common on the face and upper body. The hormonal changes of puberty may result in changes in activity of these glands -that, plus genetics, and excessive growth of the bacterium Propionibacterium acnes, all contribute to the unfortunate timing.
An article last summer in the BBC News reminded me of the consequences that affected a patient I once saw in my office for gynaecological consultation. http://www.bbc.co.uk/newsbeat/article/36712810/doctors-warn-acne-could-become-resistant-to-antibiotics
The waiting room was full that day and I saw Janice sitting quietly in the corner, her face almost buried in a magazine. She was a tall, thin, sixteen-year-old wearing tight designer jeans with a cream-coloured baggy sweater and beautiful deep blue hijab that she wore sufficiently loosely around her head that, even when she looked up, seemed to cover most of her face.
At first I wasn’t sure what to make of this. I wondered if it might be a cultural, or religious requirement for seeing a male gynaecologist -or merely a teenage affectation. But apart from her continuing reluctance to expose her face, she seemed more at ease once she was seated in my office.
The consultation note from her GP was one word: Contraception!! -with two exclamation marks. I took that as a sign.
“So, what can I do for you, Janice?” I usually like to let the patient tell me why they were referred; it’s sometimes different than what the family doctor thinks.
She shrugged. “Birth control, I guess…” But she seemed rather unsure.
I smiled and tried to make eye contact, but she continued to look away, first to a painting on the wall beside her, and then to the other wall where I had placed a terra cotta statue of begging woman on an oak stand. Janice seemed to favour the statue.
“Is that for tips?” she said, indicating the bowl the woman was holding in front of her. It was filled to overflowing with coins.
I laughed and shook my head. Everybody seems to ask the same question, and then puts a coin on the pile. “I’m not sure why some people do that, but I empty it from time to time and give it to real people begging on the street. I like to think that’s what my patients want me to do with it.”
She turned her head to look at me and I could see a smile peeking from the shadows inside the hijab. “I didn’t bring any change…”
My smile broadened. “That’s okay, I’ll put a coin in the bowl later for you if you like.”
The hijab nodded.
I settled back in my chair. “So you want to discuss contraception, Janice?” Another nod. “What have you been using so far?”
She shrugged. “Condoms at first…” She hesitated and then sighed. “Then when we got to know each other better, I went on the pill.”
“Is that what you’re on now?”
She shook her head. “They didn’t work. Well…” She lowered her head, so all I could see was the top of her hijab. “Actually, I kept forgetting to start them again after my period…” Two eyes peeked timidly from the shadows on her face. “So I had a couple of… accidents.”
She said the last word in a whisper I could hardly hear as she lowered her head to look at her lap. Suddenly, her head jerked upwards to face me and she pulled the hijab back so I could finally see her face. Both her cheeks were rough and jagged seas of red nodules, some weeping and moist, some merely little cysts about to burst. I could understand why she had chosen to wear her hijab as she did.
“My GP tried me on several kinds of treatments for the condition, but none of them helped. In fact, it was getting worse, so she sent me to a dermatologist. And she just put me back on higher doses of some antibiotic I’d already been on: mino-something.
She nodded, and her eyes filled with tears, so I handed her a tissue from the desk. “But she said it was dangerous for a developing baby, so I had to stay on the birth control pill.” She looked up at the ceiling for a moment, shaking her head. “I told her I kept forgetting to take them, but the doctor just shrugged and told me to write little notes for myself… Stupid woman!
“After the second abortion, my boyfriend and I decided the birth control pills didn’t work so I stopped them. When I told my GP about it, she took me off the antibiotics, too… I guess because she thought I might get pregnant again…” She wiped her eyes and grabbed another tissue from the box I kept on the desk. “And now look at me!”
Her eyes flitted around my face for a moment, and then she summoned them back. “They wanted to put an IUD in me at the time of the second… procedure, but I wouldn’t let them.” Her eyes found mine again. “They recommended the hormonal one.” She seemed on the verge of tears again. “But they told me it might worsen the acne.”
All of a sudden, she leaned over the desk towards me –as if she wanted me to really see what she had to deal with. “I can’t stand my face like this!” She sat back in her seat again. “My boyfriend has already left me; my friends whisper behind my back. Everybody is afraid to look me in the face…” She grabbed a handful of tissues this time and dabbed her cheeks when she’d dried her eyes. “I’m really confused, doctor. Nobody seems to know what they’re doing; they keep changing their minds…
“I can’t go on like this! I can’t…” She took a deep ragged breath. “I need somebody to tell me what to do before I fall off the edge… Or jump,” I heard her whisper into the folds of her hijab.
And then her eyes almost bored into my skull. “Can you help me, doctor?”
Her expression worried me; she was desperate and clearly in crisis -obviously at that edge. I had to do something.
“Tell me, Janice, when you were on both the pill and the antibiotics that last time, was your acne improving?”
She nodded vigorously. “The doctor told me the hormones in the pill sometimes help.”
I smiled in agreement, although I didn’t feel comfortable dealing with acne; I suspected she needed to go back on the antibiotics and her GP was right, she needed absolute protection against pregnancy while she was on them. Minocycline is a class D drug –meaning there is positive evidence of human fetal risk.
And then something occurred to me. “Was it only when you were restarting the birth control pill after your period finished that you forgot to take them?”
She nodded, obviously embarrassed. “There was a lot going on in those days…”
“But you were happy with the pill? I mean it wasn’t giving you any problems?”
“No… except for the pregnancies.”
“So, if you didn’t have to stop the pill for a period, would that work for you?” I watched her closely. “I mean, do you think you would remember to take them?”
She nodded carefully, and stared at me. “Yes… But you mean I wouldn’t have any periods?”
I nodded. “You can take the birth control pill every day for three or four months at time –or even more- then stop and have a period.” Sometimes the simplest solutions work the best.
She thought about it for a moment. “Uhmm… But if I didn’t get my period, how would I know I wasn’t pregnant?”
A good question. I smiled what I hoped was a reassuring smile. “Well, it’s true that Minocycline can interfere with the absorption of the pill, but the risk of pregnancy is still low. And you should supplement the pill with a condom.” I waited till she made eye contact again. “In fact, if you’re starting a new relationship, wouldn’t condoms be a reasonable precaution anyway?”
The acne made way for a face-swallowing smile. “I’ve sworn off sex… Well, at least until I get my face back.” I could tell she was blushing, even under the hijab. Even under the acne.
But I could finally hear some hope in her voice, and I was reminded of another verse from Shakespeare: ‘I will go wash; and when my face is fair, you shall perceive whether I blush or no.’ It seemed fitting, somehow…