Woman Whose Acne Flared After Stopping the Pill — Free SCA Practice Case

Character Overview: You are Nadia Chowdhury, a 26 year old recruitment consultant who spends most days on video calls with clients and applicants. You live with your boyfriend Sam, and your parents and sister live nearby. You are taking this call at lunchtime from a small meeting room at work, wearing a full face of makeup.

You had spots as a teenager and went on the combined pill at 17 for painful periods. Your skin cleared and stayed clear for years. You stopped the pill about six months ago, and within six weeks deep, painful spots began along your jaw and chin. The gel has not helped. Your friend Hollie at work took tablets from the hospital skin clinic last year and says they cured her skin, so you want the same. You do not know what they are called.

You do not volunteer why you stopped the pill. The real reason is that your cousin Ruksana had a blood clot in her lung last year while on the pill, and it frightened you. You explain this only if asked why you stopped.

You are friendly and chatty, but embarrassed and a little flat. Your voice drops when you talk about your face and speeds up, anxious, when clots come up.

Opening Sentence: "Hi, thanks for calling. So my skin's been really bad since I came off the pill, and the gel I was given just isn't doing anything. My friend at work had some tablets from the hospital that she says cured her spots completely. Is that something I could have?"

History if Asked (Data Gathering Phase)

• ●Where the spots are and what they are like: "Mostly along my jaw on both sides and round my chin, a few down my neck, the odd blackhead on my forehead. Nothing on my chest or back. There are two sorts. Loads of little red ones, some with yellow heads, fifteen or twenty at a time. And big, deep lumps under the skin that really hurt. They never come to a head, they just sit there for two or three weeks. Usually four or five at a time. As soon as one goes down, another comes up."
• ●Marks, picking and periods: "Brown marks that take months to fade, and in the last couple of months two or three little dents on my chin. I pick at the little ones once they've got a head, I know I shouldn't. They're definitely worse the week before my period."
• ●How it started and which pill: "I went on the pill at 17 for painful periods and within a few months my skin cleared. It stayed clear the whole time. I came off it about six months ago, and within about six weeks the spots started, right when my periods came back. It was the one with levonorgestrel in it, the same throughout, no problems."
• ●How she has used the gel: "About fourteen weeks. At first it stung and went red and flaky, so for a couple of weeks I only used it every few nights. Since then it's every night, but I just dab it on the spots. Is that wrong? It's bleached two of my pillowcases. Honestly, no difference, and I've never had tablets for my skin."
• ●Makeup and skin care: "Full coverage foundation and concealer every day, I can't leave the house without it. I take it off with coconut oil because it's meant to be gentle, and sometimes I fall asleep with it still on."

Ideas, Concerns, Expectations

Gating note: Nadia does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for today.

• ●Ideas: She thinks coming off the pill sent her hormones haywire and that the pill was only hiding what her skin is really like. "I need something stronger, like Hollie had."
• ●Concerns: Her main fear is scarring. "My dad had terrible spots when he was young and his cheeks are really pitted. Now I'm getting dents on my chin, and I'm scared I'll end up with skin like his." If the doctor explores further: "I've started turning my camera off on client calls."
• ●Expectations: Something stronger than a cream, ideally Hollie's tablets, and not to go back on the pill. "Or at least something that actually works, not another cream."

If Asked: Medical History and Medications

Gating note: Nadia answers each of these plainly when the doctor asks. She explains why she stopped the pill only if asked why, and gives the details about Ruksana only if asked more about it.

• ●Past health: "Painful periods when I was younger. Anxiety at uni, six sessions of counselling helped, fine since, never any tablets."
• ●Why she stopped the pill: "Honestly? My cousin Ruksana had a blood clot in her lung last year. She was on the pill. She's 28, totally healthy, and she was in hospital for a week. It really scared me, so I just didn't start my next pack."
• ●More about Ruksana, and family clots: "It happened a few days after a really long flight back from visiting family in Australia. Tests said she hadn't inherited anything. Mum, Dad and my sister have never had a clot. I don't get migraines."
• ●Periods and hormones: "Regular since they came back, every 28 to 31 days. My last one started ten days ago and was normal. No extra hair, no thinning on my head, weight about the same."
• ●Medicines and contraception: "Just the gel, and vitamin D in winter. No steroids, protein shakes or supplements. No allergies. We use condoms every time. We want to save up for a flat first, so no baby for a few years, and I can't be pregnant."
• ●What she knows about Hollie's tablets: "From the hospital skin clinic. Her lips went dry and cracked, she kept getting nosebleeds, and she had to do a pregnancy test every month. But her skin's perfect now."

Social History and Lifestyle Impact

• ●Work and impact: In the office three days a week, home two. "Last month I skipped my best friend's birthday drinks because of the lumps on my chin. Some mornings I cry in front of the mirror before work."
• ●Mood: "It's getting me down. I feel ugly. But I'm sleeping and eating okay and I still enjoy things when I'm not thinking about my face. I wouldn't say I'm depressed." Asked directly about harming herself: "No. Never anything like that."
• ●Relationship and habits: "Sam says he doesn't even notice. But I notice." A couple of glasses of wine at weekends. Never smoked.

If Asked: Associated Symptoms

• ●Negatives, grouped: no fever and she feels well in herself; no joint pains; no spots that have burst into raw sores or bleeding crusts, "they're just lumps"; no headaches or eyesight problems; no new medicines before the spots started.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that Hollie's tablets can only be started by a skin specialist, or what they involve:
  • ●Reaction: Disappointed. "So you can't give them to me?" Told that antibiotic tablets come first and count towards a referral: "That makes it feel less like I'm being fobbed off." Told about pregnancy prevention: "So that's why Hollie had all those pregnancy tests. Are condoms on their own not enough?" If pill plus condoms would count: "So if I went back on the pill and kept using condoms, that would cover it?" Told about mood effects: "With my anxiety at uni, would they even let me have it?"
• ●If the doctor suggests antibiotic tablets, or explains how to use the gel:
  • ●Reaction: Wary. "Antibiotics for three months? Isn't that bad for you, with resistance? Will it mess my stomach up?" On the gel: "So the whole area, not just the spots? Nobody told me that. What do I do when it stings?"
• ●If the doctor suggests going back on the pill, a different pill, the implant or a coil:
  • ●Reaction: Anxious, speaking faster. "After what happened to Ruksana? I'm honestly scared of it." If the doctor explains her own risk with real numbers, including that Ruksana's clot followed a long flight and that a cousin is not close family: "So it's about five in ten thousand a year on that pill, and two if I'm not on anything? Okay. That's not what I'd built it up to be in my head." If the choice is left with her: "If it's the same one I was on before, I think I'd go back on it." If her fear is brushed aside: "With respect, she nearly died." About a different pill: "Is that one riskier for clots?" About the implant or coil: "My sister's implant made her skin terrible. Is there a coil without hormones?"
• ●If the doctor asks to see her skin on camera, or advises on makeup and skin care:
  • ●Reaction: Declines, embarrassed. "I'd really rather not. I'm in a meeting room and the light's awful. Could I come in?" She is relieved when an appointment is arranged. On makeup: "I can't go out without it." She accepts oil free makeup removed every night. "My mum says it's the chocolate and takeaways. Should I cut them out?"
• ●If the doctor talks about referral, the review date, the dents or safety netting:
  • ●Reaction: "Twelve weeks feels like forever. What if it gets worse? How long's the wait for the skin clinic?" On the dents: "Will they go? I don't want Dad's cheeks." She accepts an honest answer. If told only "come back if it gets worse": "Worse how? What would actually mean I need to ring you sooner?"
• ●If the doctor offers talking therapy or support for her mood:
  • ●Reaction: Unsure. "It's my skin, not my head. If my skin got better I'd be fine." She is open to it if offered as an option rather than an instruction.