Checking under the hood

Emily, a 33-year-old stockbroker, came to my office. She told me that she had very
mild acne as a teenager that cleared up by the time she was 19, but returned out of
nowhere. Since then, she’d noticed increasing numbers of red pimples on her chin
that tended to appear regularly a few days before her period and lasted only for a
few days. Some of the bumps seemed to come from under her skin and many of
these remained in place for a long time.
When I looked at her face, I noted that she had a few, very subtle reddish blotches
on her chin, but otherwise had an almost perfectly clear complexion. Then she said,
“Oh, you should have seen my face two weeks ago when I made this appointment!
I can’t believe it. It’s just like when I brought my car in to have the auto mechanic
check out a loud squealing noise and — of course — it didn’t squeak or even squeal
when he test drove it!”
Based upon her history, I concluded that she had typical adult-onset acne that has
its ups and downs, and I just happened to be seeing her on an up day. I also sug-
gested that she might need a new fan belt for her car.
I then prescribed a prescription gel for her to apply to her skin. I suggested that she
apply it daily and I explained that it might help to break her adult-onset acne cycle.
She scheduled a return appointment. As it turned out, she canceled the return visit,
and several months later, she sent me the following note: “Thanks! My face is pretty
clear now, but my car still squeals.” I guess I’ll stick with dermatology!