Nothing Added
“Doctor, what product should I add?”
She was still standing when she asked, holding a large canvas bag against her side. Before I could answer, she placed it on my desk and turned it upside down, sending an assortment of bottles, tubes, jars, and serum droppers across the surface. One bottle rolled toward the edge, and she caught it just in time, smiling a little apologetically at the mess she had made.
There were twenty products altogether, enough to cover most of the desk. Cleansers, moisturizers, exfoliants, acne treatments, and several serums whose purposes were not immediately obvious. Some looked like the same choice made twice, others like choices that had nothing to do with each other.
She had brought everything because she wanted me to see what was already there, not to have it reviewed. She wanted something new, another product that might finally succeed where the others had apparently failed. Twenty products in, she still believed the answer could be found in the twenty-first.
I looked at the products spread between us and then at the woman who had sat down opposite me. I could have started discussing ingredients, comparing formulations, or suggesting an alternative, but I knew almost nothing about how she had assembled this routine, what she expected from each product, or what had happened when she used it.
She was waiting for a recommendation.
I had questions.
I asked her to show me what she actually used, rather than simply what she owned. She leaned forward and began arranging the containers in the order she applied them, starting with her morning routine and then moving to the evening. I wanted to understand how often she used each product, when she had introduced it, and whether she had noticed any changes since then. Two products could look almost identical on my desk and yet play very different roles in her daily routine.
As she moved from one container to another, I asked her to explain how she combined them. Some products might be perfectly reasonable on their own but less useful, or even irritating, when used alongside everything else. Others might have a purpose that neither their ingredients nor the claims on their packaging explained. I was not deciding anything yet. I was trying to understand what was happening on her skin, rather than what each product was supposed to do in isolation.
Then I picked up one of the containers and asked a different question.
“What were you trying to solve when you chose it?”
I was interested in the problem she had hoped to address, not just the product she had selected. What had made that particular choice seem necessary at the time? What had she expected to happen, and what had actually happened?
The products were still spread between us, but I was beginning to see something that had not been visible when they first spilled out of her bag: the decisions behind them. Before I could decide which products deserved to stay, I needed to understand why they were there.
READING THE BAG
She picked up one of the jars she had arranged in front of me and handed it over so I could read the label. Non-comedogenic. A bottle beside it carried another familiar claim: non-acnegenic. She pointed out both, explaining that these were among the reasons she had chosen them.
Neither claim was necessarily misleading, but neither answered the question we were now trying to resolve. A non-comedogenic or non-acnegenic label may make a claim about a product, but it cannot tell us whether that product belongs in this patient’s routine.
We went through the containers together, comparing what each was intended to do with how she actually used it. Some appeared to serve similar purposes, while others contained active ingredients that required particular attention when used alongside her acne treatments. A product might be appropriate on its own and still contribute to an unnecessarily complicated routine. Another might be useful, but not in the way or at the frequency she had been using it.
I was also careful not to assume that the number of products explained her acne. A desk full of containers was not evidence that cosmetics had caused her breakouts, and reducing their number would not, by itself, establish a treatment plan.
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She watched as I returned the jar to the place she had given it. The products were still arranged in the order of her morning and evening routine. Nothing had been removed.
But we were no longer looking at them in quite the same way.
THE DECISION
“What needs to change?” I asked.
She looked at the products she had carefully arranged for morning and evening use. Until then, their position had told us when she applied them, but very little about what each contributed to her routine. Before moving a single container, I examined her skin, looking at the type and distribution of the acne lesions and checking for signs of irritation. Only then did I return to the products and begin moving them into separate groups, explaining what I was looking for as we went.
The first group contained repetitions. Different brands, different formulations, sometimes different prices, but products intended to accomplish essentially the same thing. We compared them with what she had told me about her skin, and I asked whether she could identify a particular benefit from using more than one. In several cases, she could not.
The next group required a different conversation. Some products were more than redundant; the way she combined them seemed to be contributing to irritation. Among them was the bottle she had caught before it rolled off the desk. It was an exfoliating cleanser she used on evenings when she also applied another exfoliating product and one of her acne treatments. She described the stinging and tightness she had gradually come to accept as part of her routine. We discussed why those sensations were not evidence that the products were working better.
A third group began to form from products she had purchased for concerns that her history and her skin did not confirm. There was nothing inherently wrong with the products themselves. They had no clear role in what we were trying to achieve.
I moved the products we had agreed to discontinue back into the open bag, one group at a time. The bottle she had saved from falling went in with the others. What remained on the desk was a much smaller selection, each product serving a distinct purpose that I could explain and that she could recognize.
She looked at the remaining containers and began asking about their order, how frequently she should use them, and what changes she should expect.
For the first time during the consultation, we were discussing a routine she could follow, rather than another product she might need to buy.
ADULT ACNE DECISION SPACE: ROUTINE CHOICE
As she began to understand the role of the products that remained, I thought about how differently this consultation could have unfolded if I had answered her first question immediately. I might have recommended a perfectly reasonable product, supported by clinical evidence, without ever discovering what she was already doing or why she had chosen those products in the first place. The recommendation might have been correct in isolation and still wrong for her.
I explored this distinction in Adult Acne Decision Space: The Eight Layers Behind One AI Search — Victor G. Clatici, MD, September 30, 2026, where the fourth layer is ROUTINE CHOICE — Should I change my skincare? A product can have a legitimate place in acne care without necessarily belonging in a particular patient’s routine. The decision may involve adding something, removing something, or reconsidering the role of what is already there. Sometimes the answer lies outside skincare altogether.
And if she had typed her opening question into an AI chat instead of asking it across my desk, what would the system have needed to know before recommending one more?
The patient came for her 21st product. I removed 17. Nothing added.
Victor G. Clatici, MD
In dermatology since 1995
MedAIMark | Doctor-Led AI Search for Dermatology & Aesthetic Brands
