It was very strange how resistant a twenty-three-year-old woman's acne was to treatment. For months we watched one treatment after another fail. Her face continued to exhibit a full complement of blackheads, redness, and pustules at every visit. Local treatments achieved little, other than camouflage. A full array of systemic antibiotics staggered from the fray, accomplishing little more than inducing a yeast vaginitis. Even the acclaimed Accutane® failed, despite its advertising hype, “you've never seen results like this.”

Was there a hormonal problem? No, her menses were normal and androgen, the prime mover of acne, was shown to be at low levels in her blood.

Was it genetic? No one in the family had had serious acne. Was it due to food imbalance? We had seen a case of terribly resistant acne in a Naval cadet who, disliking the Navy chow, ate nothing but Hershey bars. Could it be due to an intake of nuts, long known to us as a cause of postadolescent acne? No, her diet was balanced and a nut-free regimen had not had the slightest effect. Could it be due to a drug, such as dilantin? No, she was healthy and avoided all medications.

We explored her cosmetic history. No, she did not use occlusive greasy makeup which produces poral closure with subsequent acne. Nor did she use sunscreen lotions. Furthermore, she used no hair pomades. Her habits were obviously not the cause of her distress.