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You might’ve heard celebrities swear by drugstores finds (Constance Wu told The New York Times “The Clearasil face wash. Seriously.”) or diet remedies, but when over-the-counter (OTC) options stop working for acne, many people find themselves turning to prescription.

Isotretinoin, specifically, was the “top selling product […] with sales of USD 1.2 billion.” (This is the most recent data on acne prescription, from 2016). You might know it as the generic version of Accutane, which was pulled from the market in 2009.

Isotretinoin effectively works by decreasing the amount of sebum on your skin, taking away a major factor to creating acne lesions.

You’ll find them in the form of “antibiotics, retinoids, anti-hormone, and isotretinoin,” says Jennifer Hollander, a board certified nurse practitioner who has experience working in both clinical and cosmetic dermatology.

And while many have great success with this pill, there’s a lot of stigma and even fear associated with oral isotretinoin. If you’re wondering if this is the right skin journey for you, here’s how to prepare yourself.

As someone who had severe acne, I remember wishing there was a way they could just suction all the pimples off my face. Acne is painful for the skin and self-esteem, and there are studies covering how it can cause or worsen depression. It’s definitely more than a cosmetic condition!

And there’s nothing inherently wrong with taking antibiotics or other prescribed medications to treat acne either, but it’s essential to discuss the side effects, both mental and physical with your derm. (I was actually on Accutane in the early 2000s, so more on that later).

Just as there isn’t one cure-all for people who experience acne, it wouldn’t be accurate to say that people should or should not use acne medication.

Your decision will be more nuanced than that. And if you’re tired of wasting money on products, you may be interested to hear that treatment-resistant acne usually actually requires prescription medication.

Isotretinoin is the closest thing to a cure that we currently have for acne and everyone’s acne will eventually improve on treatment.

Isotretinoin, which can treat all forms of acne, is most often used for people:

  • who have scarring from acne
  • whose acne is not responsive to other OTC and/or other more conservative prescription treatments
  • who have other skin conditions like rosacea
  • who have severe acne, such as nodulocystic acne

“It’s important for consumers with scarring acne to see a doctor to get effective acne medication and not waste money and time on OTC treatments while their scarring continues,” Dr. Sandy Skotnicki, dermatologist and author of Beyond Soap says.

“Patients with very severe cystic acne need medication to treat their condition.”

Isotretinoin is effectively high doses of vitamin A, which if you have too much of can cause side effects seen with too much Vitamin A called hypervitaminosis A. Vitamin A is stored in the liver, so chronic, excessive intake can be harmful.

You’ll want to avoid vitamin A supplements during this time.

Psychiatric side effects

Psychiatric side effects related to isotretinoin are controversial but historically have thought to include a potential increased risk of:

  • depression and suicidal ideation
  • psychosis and mania
  • anxiety
  • stress

Physical side effects

Since isotretinoin works by decreasing the amount of oil in your skin, almost every single person will experience dry skin, chapped lips, and a dry nose (to a point of nose bleeding), depending on the dosage given.

It also increases the risk of sunburns/sun sensitivity. Joint aches or muscle aches are also relatively common in very active individuals.

A worsening of your acne in the initial period of treatment is also common and is not a reason to stop treatment. Let your dermatologist know immediately if it is severe.

Other reports of physical side effects that should be reported to your doctor as soon as possible if they occur when taking the medication include:

  • headaches and dizziness
  • blurred vision and/or difficulty seeing in the dark
  • nausea or vomiting

You might have read about concerns of isotretinoin causing inflammatory bowel disease but studies have largely debunked this association.

Don’t take it while pregnant!

Before you start isotretinoin, you have to register for the iPLEDGE program, which was put in place to help prevent birth defects caused by isotretinoin:

  • If you can become pregnant, you have to use two forms of birth control and provide two negative pregnancy tests before you can pick up your prescription.
  • If you can’t become pregnant, you still need to enter the program before your prescription will get filled, but you won’t be asked to have proof of a negative pregnancy.

1. A derm will work with you to figure out the dosage

“The standard dosage for isotretinoin is given in two divided doses, with food, for 15 to 20 weeks,” Hollander says. “The dosage is weight dependent and can be slowly increased at subsequent office visits.”

Typically a dermatologist will start you at 0.5 mg/kg per day (based on your weight). Then they will bump your dosage up to 1.0mg/kg per day after the first month, if your body seems to be tolerating the medicine.

Capsules are meant to be taken whole, and about 80 percent of people will see clear skin within 4 months, although treatment course is often based on weight.

The total length of a treatment course can range from 120mg/kg to 220mg/kg. The average course takes 4 to 6 months and folks who need more will have to complete an additional 4 to 6 month treatment.

2. You’ll see your derm every month for monthly check ins

After starting isotretinoin, you’ll also need to see your dermatologist monthly. “Labs are drawn every month to monitor liver functionality,” says Hollander. Other tests ordered may include a lipid panel, a complete blood count, and even a pregnancy test.

If your lifestyle won’t allow for this regularity of appointments, then you may not be a good candidate for the medication.

3. Stay hydrated throughout the process!

“I always encourage patients to drink a ton of water while on this medication and keep a small tube of Aquaphor handy. Patients should also be applying an SPF of 30 or higher on the face and body as they are at a higher risk for sunburns,” Hollander says.

Dermatologists will often recommend stopping all other acne products and prescribe a sensitive face wash and moisturizer.

Oral isotretinoin is very drying and so hydrating skin products should be the focus of your skin care routine, instead of acne-fighting ingredients, which may cause extra irritation.

It never hurts to double exhaust all your options if you don’t want to take isotretinoin. How well treatment works ultimately differs from person to person, and it’s worth making sure your anxieties are soothed first.

1. Figure out dietary, environmental and lifestyle stressors

“Your esthetician will want to dig into your diet, environmental stressors, and lifestyle habits that may be exacerbating break outs,” says Catherine Richardson, an esthetician and owner of Holiday Organic Skin Boutique in Boston, MA.

“Exposing contributing factors gives you the opportunity to make small changes and pivot onto the path of a complexion you’re proud of.”

2. Keep your products hydrating and simple

Avoid scrubbing, Skotnicki says, and wash your face at night. She also recommends using OTC treatments with salicylic acid and Benzoyl peroxide, at 2.5–5 percent after.

Richardson also suggests hydrating, vitamin A-rich beauty products. “I recommend Blissoma’s Smooth A+ Serum and Pure moisturizer to clients looking for alternatives to traditional acne treatments.”

3. Be consistent with your routine

While the beauty aisle and it’s candy-colored packaging may be calling to you, it’s best to stick with the same products for at least 28 days, or in some cases 3 months (such as with a topical retinoids).

28 days is about the length of time it takes for the outer layer of skin to regenerate. “Consistency leads to beautiful skin,” Richardson says.

4. Make diet tweaks

Low inflammatory diets may be beneficial,” Skotnicki says. Most people also report wins when limiting sugar and dairy.

Surprisingly, there is some evidence that low-fat dairy can make acne worse, but these studies need stronger links before we pour the skim milk down the drain for good.

When it comes to chronic acne, a dermatologist and an isotretinoin prescription may be a better acne army, especially if you have severe cystic acne, or otherwise treatment-resistant breakouts, with scarring.

But if the potential side effects make you worry, don’t be afraid to keep asking questions, seek alternatives, or get a second opinion.

Ultimately, feeling empowered and confident with your choice means finding the middle ground between your comfort and needs.

Grace Gallagher is a writer living in Portland, Oregon. All of her work can be found at www.gracelgallagher.com.