I’ve already shared via this blog just how much acne affected my young adult life. The years I spent struggling to achieve clear skin are part of the reason I became a dermatologist. During my teenage years, I tried every over the counter or holistic remedy I could find to little and sometimes counterproductive effect. When all that failed, I sought out the help of a dermatologist. I spent several years going from doctor to doctor trying various prescription medications including topical retinoids and antibiotics, and while my skin got better, nothing ever got me totally clear. Even more frustrating was the fact that my breakouts were unpredictable, and that some left me with permanent scarring.
By the time I had made it into my twenties, I had exhausted most all of my options save for the systemic retinoid isotretinoin (formerly sold under the trade name Acutane ™ , which many still refer to it by). While I had previously entertained the idea of taking the plunge and finally going through with what had been presented to me as “the last resort,” I had never been able to in the past due to terrible prescription coverage that wouldn’t pay for it and a schedule that was prohibitive of monthly doctor’s appointments. However, by this point I had had enough. I decided to find the time between my more-than-full schedule of undergraduate studies and two jobs to do my course of isotretinoin while scraping together what turned out to be several thousand dollars, all in the name of clear skin.
It was worth it.
What follows is my personal experience on the medication, which I’m sharing to give more detail about what the process and day-to-day experience is like for those who are on the fence or just curious. Full disclosure: I recently had to repeat a course of isotretinoin after 7 years and I’m just as happy with my result now as I was after the first go-around. I’ll talk about both courses generally, but most of the info here will be based on my more recent course since I can remember it better. As always, make sure you speak with a board-certified dermatologist for all of your acne concerns.
The process of getting and taking the medication
The process of getting this medication is difficult for both the patient and the prescriber, and I’ve been on both ends of this process. I could talk about this issue for hours, but to put it simply: prescriptions of isotretinoin are tracked by a program called iPledge – a Risk Evaluation Mitigation Strategy implemented by the FDA. Why? Isotretinoin can cause severe birth defects if taken by someone who is pregnant. As a person who cannot get pregnant, I had to enroll in the iPledge program – this meant filling out forms in my doctor’s office as well as online, obtaining a special ID card that I had to take to the pharmacy to pick up my medication, and going back to my doctor for monthly visits for the 5 or 6 months I was taking it. In addition to this, I had to get blood tests done to track various parameters, most importantly a level of fat in the blood called triglycerides – this was done monthly for my first course, and only a few times during my more recent course based on new scientific data. Obtaining this medication is harder for people who can get pregnant (you are required to make a pregnancy prevention plan and have monthly pregnancy tests) – more on that in a later post.
As for actually taking the medication, I started with a lower dose (40 mg) for my first month and moved up to a higher dose (80 mg) for the rest of my course. I took the entire dose once daily with a fatty meal, as this helps with absorption. You can also split your daily dose up so that it’s taken twice per day – best to discuss dosing schedules with your doctor before starting isotretinoin. The length of the course is dictated by when breakouts stop, as well as the overall cumulative dose of medication taken.
How my skin (and skincare) changed while on isotretinoin
This medication will make you DRY! That’s because of one of its main mechanisms: inhibiting and basically reprogramming the oil glands in your skin. This also means dry skin, lips, eyes, hair etc. are par for the course and I experienced all of that. The first month came with chronically chapped lips. By the time I got to my cruising altitude of 80 mg I had some flaky facial skin and more dryness than I was used to on my body. This meant a total overhaul of my skincare routine. Going from a skincare regimen for acne-prone skin to one where I was basically greasing myself up several times per day took some mental acrobatics. I had spent most of my life paranoid about the comedogenicity of the substances I applied to my skin, the pillowcases I slept on, the air I breathed. Now I had to leave all that behind. It was actually refreshing.
I got by on a program that included a very mild cleanser, thick, bland moisturizers and ointments for face and body and daily sunscreen. I also carried both ointment and lip balm around everywhere I went and applied them multiple times per hour. I tried to hydrate as much as possible by drinking a lot of water. By the end of month 1, I noticed that my pores had shrunk. I had very prominent pores on my nose with some blackheads in the time leading up to starting isotretinoin and I noticed that the texture of my nose started to change and I could almost feel the comedones starting to poke out. I did a pore strip, which in retrospect was a terrible idea (this medication makes your skin fragile so don’t do this!) and I felt like it purged years’ worth of oil and dead skin cells from my pores. By month 2 I noticed an intense glowy quality of my skin, like the type you get from topical retinoids but way more pronounced. My skin continued to be drier and feel more sensitive than usual. By a few months in I was noticing no new pimples.
Any other side effects?
At the end of my second course I started to have pretty bad angular chelitis (irritation and cracking at the corners of the mouth) which was part of the reason I decided to finish that course. Lip balm and ointments were helping, but by that point I hadn’t had any acne in months and I’m glad in retrospect that my doctor and I decided to leave it there. It cleared up right after I stopped the medication. I had muscle pains after exercise once or twice – this is a known side effect and didn’t alarm me at all. This medication carries a black box warning for depression and suicidality (neither of which has been validated by scientific evidence). My mood was great throughout both courses. Seeing my skin clear within the first few months made me immensely happy, especially the first time around.
Why I took a repeat course
After I had been off of isotretinoin for about 5 years I started to develop acne again. It was by no means as severe as it had been before, and I was able to manage it for the first year and a half by using a topical retinoid and keeping my skincare routine as noncomedogenic as possible. After that I started breaking out more frequently. I tried a course of oral antibiotics which helped somewhat, but I had a rebound break out right after stopping. My doctor and I decided to repeat a course of isotretinoin at that time. While there isn’t great data to say definitively when or if isotretinoin loses effect over time as a rule, we do know that about 20-30% of patients relapse in the months or years directly after their course. Knowing this, I felt confident taking another course of the medication.
Life after acne
Michelangelo had this idea that all of his sculptures were complete in the marble block before he started his work—he just chiseled away all the superfluous material to reveal what was inside. I feel the same way about the process of getting rid of my acne – this was a step not only to achieve clear skin, but also to become who I really am. This was immediately apparent to me after my first course. It was like seeing myself for the first time.
I also realized just how much of my time and energy had been spent on my skin before. Achieving clear skin didn’t just alter the way I looked but also improved my emotional wellbeing and changed how I spent my time. I now live without the constant paranoia that each skincare product I use or food that I eat may break me out. It’s hard to understate just how important that has been for my overall wellbeing.
If you’re struggling with acne, I encourage you to see a dermatologist and start your own journey to clear skin.