Patient description: A 35-year-old woman presents with history of acne and mild hirsutism. The primary evaluation revealed elevated testosterone levels. She recently noticed gradual enlargement of her hands and feet and recognized that her ring is getting small for her finger. There is some irregularity in her menstrual cycle as well as some nipple discharge. She also has positive history for snoring and headache. The physical examination revealed subtle facial features of acromegaly and prognathism. Visual fields are normal by confrontation. Hirsutism, soft tissue thickening and diaphoresis of the hands and feet are noted. Laboratory evaluation in the fasting state reveals IGF-1 of 968 ng/mL and random GH of 19.7 ng/mL. MRI reveals a macroadenoma with no invasion. She is on stable doses of octreotide LAR since her diagnosis was confirmed. She is married and has 2 children. She is using IUD as her contraceptive method.

Clinical trial eligibility criteria: eligible ages (years): 12.0-54.0,  Severe Nodular Acne Severe recalcitrant nodular acne, which in the opinion of the investigator is compatible with isotretinoin treatment Ten (10) or more nodular lesions (facial and/or truncal) Treatment-naïve patients without any prior exposure to systemic isotretinoin or other retinoids Age between 12 and 54 years Weight between 40 and 110 kg Negative serum human chorionic gonadotropin (hCG) pregnancy test consistent with a non-pregnant state (females only) No significant disease or clinically significant finding in a physical examination No clinically significant abnormal laboratory value No clinically significant abnormal vital sign measurement Patients presenting with stable and controlled diabetes mellitus (Types I and II) may be included in the study. However, patients should not have had a hospitalization for any diabetes related complications in the last 12 months, and must be on stable medication for the preceding 6 months. To be included in the study, the patients should have Hemoglobin-A1c values ≤ 6.5% at screening and in the test done 3  Female patients will be excluded from the study if they Are pregnant Are at high risk for becoming pregnant or likely to become pregnant during treatment Will be breast-feeding or considering breast feeding during the course of the study Known history or presence of any clinically significant unstable medical condition(s) which in the opinion of the investigator could pose a risk for the safety of the patient including any previous history of gastrointestinal disease Patients with any skin disease or other condition that might interfere with the evaluation of recalcitrant nodular acne Patients will be interviewed using the SCID-CT current and lifetime modules for Major Depression, Mania, and Psychosis. Patients with a lifetime history of psychosis will be excluded. Patients with a history of major depressive, manic, hypomanic or mixed episodes will not be excluded unless they have had an episode during the preceding year Patients with any past or current psychotic symptoms Patients reporting any suicidal behaviour (including attempts, interrupted attempts, aborted attempts, or other preparatory behaviours), within the past year, or serious suicidal ideation in the past year, will be excluded from study participation A lifetime history of wishing to be dead, non-specific active suicidal thoughts or active suicidal ideation without intent to act will not result in exclusion