For years, the cabinet underneath my bathroom sink was a graveyard of skin-care products, filled with the ghosts of face soaps, washes, toners, and scrubs past. Bottles of Neutrogena, Cetaphil, Proactiv, and Clean & Clear products were all laid to rest after my hopes that they would cure my blemished face were dashed, raised, and dashed again. Nothing I tried worked.
A couple years and a handful of dermatologists later, piles of prescription products were also thrown into the landfill of acne medications in my bathroom. Tubes of Retin-A, Tazorac, and Epiduo cream, and antibiotics such as doxycycline and tetracycline had all been prescribed to no avail. Whenever one pimple went away, another popped up in its place, like a game of whack-a-mole played on my forehead and chin. Even as I reached the end of my teens, when acne generally subsides, mine was only getting worse and my frustration and embarrassment continued to grow.
Eighty-five percent of young people experience some form of acne, and each year Americans spend more than $2 billion at the dermatologist trying to drive their zits away. Acne is practically a rite of passage—one that teens have gone through for centuries. In ancient Egypt, King Tut apparently suffered from blemishes, and the poor guy must have never found a regimen that worked—his home remedy was found buried alongside him in his tomb.
After spending years entombing my own failed remedies beneath my sink, my senior year of high school, I tried the first and last acne medication that would have a lasting impact. Isotretinoin (commonly referred to by one of its brand names, Accutane, even though its manufacturer pulled it from the market in 2009) was like a pimple’s kryptonite. I took two pills a day for six months and it crippled my acne for the long term.
But why does isotretinoin work so well? “We don’t really know,” Joslyn Kirby, a dermatology professor at Penn State College of Medicine, says. “That’s part of the research that people at our group at Penn State are doing, is looking into some of the changes in the oil glands in the skin called the sebaceous glands, and what is happening to the cells that might explain … this sustained improvement.”
What we do know is that the drug ultimately reduces inflammation and makes pores less hospitable to bacteria, Kirby says. It depends on the severity of the acne and how high patients and doctors decide to crank up the dosage, but the average length of treatment is four to six months. While a higher dosage, within safe limits, can reduce the amount of time on the drug, it can also make the side effects more intense.
These side effects contribute to why isotretinoin is often a last resort for curing severe acne. Extremely dry skin is one of the most common effects of the drug, but since it became FDA-approved to treat acne in 1982, it has also been linked to inflammatory bowel disease, depression, and increased rates of suicide. While studies have not proven that isotretinoin causes these conditions, they remain among the risks of taking the medication. Other serious but rare side effects include joint and muscle pain, eyesight trouble, and liver damage. Due to the drug’s impact on the liver, patients are advised not to drink, and their liver enzymes are monitored throughout treatment. Much to my high-school friends’ delight, this made me the designated driver for the majority of our senior year. If I had much more than a beer, it would show in my blood work, and I was admonished by my doctor and my mom—something no teen wants to experience.
Isotretinoin also causes miscarriages and severe birth defects if taken while pregnant. This has led to strict and cumbersome regulations. Just being able to pick up the medication each month required jumping through a series of pharmaceutical and medical hoops. The process starts with a visit to the lab for blood work. For women, the blood sample is used for a pregnancy test, and for all patients it’s used to monitor liver enzymes and blood fat levels, which the medication can cause to rise.
Patients are also required to participate in the iPledge online program. The program aims to prevent pregnancy by having patients confirm that they understand the risks of the medication, promise to keep monthly appointments with their doctor, and agree not to share the medicine or donate blood while taking the drug. Each month, women must also answer a series of comprehension questions about birth control, and their prescribers must confirm results of a negative pregnancy test.
At each appointment, after I saw my doctor and she reviewed my blood work, she would submit her portion of iPledge. Once my pharmacy received the information, usually within a few hours, I could finally pick up my prescription—so long as it was done within a seven-day window of the pregnancy test. Thirty days later, I’d repeat the entire process.
Once I finally had the pills in hand, dry skin was the side effect that impacted me the most day to day. My once-oily face transformed into a desert. A light touch was all it took for the skin on my forehead to come off in flakes, and thin layers peeled off like an onion. Chapstick became a constant necessity. Even though I was always armed with something to soothe my cracked lips (I had at least one stick in my backpack, another in my car, another in my bathroom, and others strewn about my bedroom) my lips remained unusually swollen and puffy. This was followed by nasal dryness that led to the occasional nosebleed.
As isotretinoin waged a scorched-earth strategy on my face that left me feeling like my skin was practically falling off, I was also weirdly excited by the changes I saw taking place. If I could molt my skin like a snake and discard my bacteria-ridden, blemished skin, it gave me hope that a fresh, healthy layer would finally surface.
Out of all of the drawbacks to the drug, the biggest hurdle for me was the monthly blood test. I have low blood pressure that causes me to routinely pass out after having my blood drawn, and just the sight of blood makes me queasy.
Each month I would try my best to avoid ending up in a heap on the floor of the lab. I would request the one room with a chair where I could lie all the way back and put my feet up. I’d take slow, deep breaths until the nurse removed the needle, wait a few more minutes for good measure before sitting up, and then, barring any lightheadedness, I’d breathe a sigh of relief that I wouldn’t be back in the chair for another 30 days. Still, on more than one occasion I wouldn’t make it farther than the waiting room before I’d slump down into a chair, putting my head between my knees until the dizziness would pass.
Now, however, it turns out that I might not have needed those monthly tests. In 2015, Kirby authored a study that suggested only two blood tests would be necessary: one to measure baseline levels of blood fats, and another two months after beginning treatment, when levels reach their peak. Not only would this alleviate the cost of co-pays for the procedure, but it would have relieved the anxiety of having my blood taken each month, something Kirby says many of her patients experience.
“When we tell people ‘You’ll need blood work,’ sometimes we see that fear or concern on their face,” she says. “When we can say it’s going to be just two [times], sometimes I see those faces relax.”
There were times throughout the six months that I questioned why I was putting such an intense drug into my body. There was no serious medical repercussion to letting my acne continue to go untreated. Yet after leaving one blood test particularly nauseous and lightheaded, cursing the drug, I looked in the mirror and realized I hadn’t seen my skin this clear since I was about 12 years old. It was like I had taken off a mask that I had been wearing for years and suddenly recognized myself again.
Over the years I struggled with acne, I had begun to think of it as a personal failure. Something was wrong with my skin, but I also felt like something was wrong with me because I couldn’t fix it. Worst of all, there was no hiding this failure. I was convinced it was the first thing people saw when they looked at me, because I knew it was the first thing I saw when I looked at myself.
It’s been almost five years since I stopped taking isotretinoin, and the mountain range of cysts spread across my face is long gone. I don’t worry what people see when they look at me, and looking in the mirror no longer means fixating on flaws. When I look at my reflection, I don’t see embarrassment and frustration staring back at me anymore. Instead, all I see is my face.