On My Mind

Thinking About Going On Accutane? Read This First

For most people, there are dramatic results. But we need to talk about the little-known side effects.

By Loni Venti
Shutterstock/Getty Images/Susana Ramírez/Stocksy

If you’re someone who is struggling with acne, the appeal of a pill that can make your breakouts disappear basically forever is totally understandable. If you’re thinking about taking isotretinoin (aka Accutane), you probably already know that it can be very, very effective at getting rid of acne. But it’s important to remember the reason that it’s so effective: It’s a powerful and potent drug.

When prescribed and monitored by a board-certified dermatologist (and with some lifestyle and beauty routine changes), isotretinoin can be a safe solution that drastically changes your complexion — something life-changing, especially if you’re dealing with a severe case of acne.

But it is a big commitment and a very serious decision that shouldn’t be taken lightly. Aside from creating a plan to avoid pregnancy, monthly blood work, counter-balancing the dryness and sensitivity it causes, avoiding alcohol, the sun, tattoos, and more, there are even more concerning side effects that aren’t often discussed — and longer-term reactions, too.

Before you book your appointment or start up the treatment, we want to prep you with everything you need to know to make the best decision for you. Read on for info from some of the top derms in the biz, super honest (and potentially TMI) firsthand accounts from former isotretinoin users, and more details the drug that is Accutane.

What Is Accutane, And How Does It Work?

First things first, what even is it? Here’s a chemistry and history lesson rolled into one. “Accutane, [the brand name of] isotretinoin, consists of giving an elevated dose of a form of vitamin A,” explains Dr. Rachel Nazarian of Schweiger Dermatology Group in New York City. “This helps regulate the skin cycle, increasing the speed of cell turnover, decreasing oil production from oil glands, and normalizing the natural skin flora to mimic that of healthy, non-acne-forming skin.” (Retinol and tretinoin are also forms of vitamin A, applied topically, instead of taken orally like Accutane.) She puts it simply: Accutane is the most effective treatment for acne. “You keep the results you obtain, whereas other oral treatments are a Band-Aid, so to speak,” explains Dr. Hysem Eldik, a board-certified dermatologist at Marmur Medical in New York City.

“Isotretinoin first came about in the 1920s and 1930s from trials conducted with animals and humans who were treated for vitamin A deficiency by taking oral vitamin A,” Eldik adds. As an unexpected result of the trials, acne improved — which led to further studies proving the link between oral vitamin A and acne and, eventually, the name-brand version of isotretinoin: Accutane. (“Isotretinoin is the generic name of the drug,” explains Eldik. “Accutane, Claravis, Absorica, and more are the different brand names made by different companies, but the actual drug is isotretinoin.” Think how Advil and Motrin are name brand versions of ibuprofen.)

Back to how it works. “Part of the mechanism by which it works is decreasing the size of the oil glands in the skin, and therefore decreasing oil production,” Dr. Angelo Landriscina, an NYC-based dermatologist, explains. “The goal of Accutane is to shrivel up oil glands that are the culprit for producing acne. Thus, the majority of side effects are related to severe dryness,” Eldik adds.

Potential Physical Side Effects Of Accutane

TBH, there are a lot. But not all of them are common.

Isotretinoin doesn’t just dry up your acne. It pretty much dries up… all the things. This may mean that your skin becomes very dry and sensitive, sometimes causing eczema (Eldik notes that this can be treated topically), dry eyes that may require lubricating drops, and a dry nose with potential for nose bleeds. “The lips are a major adjustment for patients,” Eldik says. “When they become very dry, they crack, causing redness and irritation.” The dryness can impact your joints, too. “Some patients report mild joint pain that resolves on its own in most cases,” he adds. “Other common side effects we see include an initial flare of acne when treatment is started, increased risk of sunburn, minor pain with strenuous exercise, and an increase in the level of triglycerides in the blood,” Landriscina notes.

All of the derms made one thing very clear: The biggest risk is birth defects if isotretinoin is taken during pregnancy. “If the patient can become pregnant, they will have to make a contraception plan with their prescriber,” explains Landriscina. “This risk goes away once the treatment course is complete and the drug is no longer present in the body.” According to Dr. Anthony Rossi Jr., also an NYC-based dermatologist, the reason this medication cannot be taken while pregnant or planning pregnancy is because of its teratogenic effects on the fetus. Teratogens can stop the development of an embryo or fetus, halt a pregnancy, or create a malformation.

Nazarian explains that this is why there is implementation of various programs (such as iPLEDGE, an FDA-affiliated program committed to pregnancy prevention) and other guidelines to ensure patients do not get pregnant while on this medication.

According to Eldik, there are no concerns about future fertility or pregnancy once you are off the drug and cleared by your dermatologist.

“A lesser-known side effect is a theoretical premature closure of the epiphyseal plate, meaning stunting growth in very young patients,” Eldik adds. “We consider this in patients with severe acne who are considering Accutane when they have not yet hit puberty. Otherwise, it is not a concern.”

There are many other effects that can happen, including gastrointestinal issues, hair thinning, and liver effects, but these side effects are rare, Rossi explains. “For the most part, the drug is tolerated very well,” he says, citing how most derms will monitor your monthly bloodwork to measure changes in liver function and triglycerides.

Accutane And Mental Health

This part gets a little complicated. The dermatologists and the various studies they shared showed little to no evidence that isotretinoin should cause depression or suicidality, but there is a constant recurring conversation connecting the two — including two of the experiences shared with Elite Daily by Accutane users we interviewed for this story.

“There has been much controversy over the possible association between isotretinoin treatment and the risk for depression and suicidality,” says Landriscina. “Much of this concern came from older case reports and retrospective studies. However, newer studies of higher quality, including prospective studies and meta-analyses, have shown no such association. ... In fact, studies have even shown that patients on isotretinoin tend to have less depressive symptoms than people undergoing other treatments for acne.” That’s because dealing with acne, no surprise, isn’t all sunshine and rainbows, and oftentimes, when your skin clears up, your self-image and mental health can improve. “That said, we can’t know for sure if there isn’t a small subset of patients that may experience mood changes while taking isotretinoin,” he says.

It’s worth noting that all the dermatologists we interviewed for this piece didn’t seem too concerned about the probability of Accutane leading to depression and suicidal thoughts, making note that they screen for a history of depression and suicidality before starting patients on isotretinoin. Just like Landriscina, Eldik shares that providers check in with patients about their mood and symptoms monthly. “We always encourage mental health evaluation and keeping a close eye on any major changes,” he says.

But just because it’s an outlier doesn’t mean it doesn’t happen. This report on Accutane in the Journal of Affective Disorders found that many “studies show individual cases of clinically significant depression and other neuropsychiatric events that, although not common, are persistent in the literature” and that “continued vigilance is needed” when taking the drug. And there are also the numbers: Nearly 18,000 cases of depression, anxiety, and emotional lability linked to isotretinoin use were reported to the FDA over the past two decades. That includes 2,278 cases of suicidal ideation, 602 cases of attempted suicide, and 368 reports of completed suicide. Just because the link is murky, doesn’t mean it isn’t there.

An important takeaway: If you are prone to depression and decide to proceed with this treatment, please mention your mental health history to your dermatologist. Even if you are not prone to depression or suicidality, if you start to experience mood swings or thoughts of self-harm while taking isotretinoin, share this immediately with your doctor. The more you communicate, the safer your experience on Accutane will be. Dermatologist Davin Lim says that if you’re concerned about side effects, you and your derm can begin by reducing the dosage to a very, very low dose and then build up slowly. “It’s not a sprint, it’s a marathon,” he says.

4 Real Accutane Experiences

So now you know the history, the trials, the studies, and what the derms think. But what about real life experiences? Elite Daily chatted with some former Accutane users and got their ultra-honest POVs.

I’m so happy with my results — but it did affect my mental health.

“I am so happy I took Accutane. Now I get maybe one pimple every two years. Nothing makes me break out. I no longer have to worry about new products giving me zits or hormonal acne. I took it for five months when I was 26. My sister was already on it, and I was curious. I begged my derm to prescribe it. He said, and I quote, ‘Don’t you dare get pregnant or I could lose my license.’ My acne wasn’t horrible, but it was just always there. I never had a completely clear face, even if it was only one to two pimples. I was sick of it. I got the same zit above my upper lip every month right before my period and it hurt. I just wanted it gone for good. The results were instant. Like, within 24 hours all the gunk in my pores rose to the surface — then, within a few days, it all came out like one of those Play-Doh spaghetti toys. It was so satisfying. All my big pimples went away, and they never came back. Toward month four, I felt fatigued and mildly depressed. I was supposed to take Accutane for six months, but I stopped after five because I just felt blah. But stopping early didn’t affect my results.” – Courtney, Missouri

If I knew the health issues it would cause, I would have never taken it.

“At the time that I used Accutane, it was a positive experience because my acne cleared up. But if I knew the health issues it would eventually cause, I would have never taken it. I saw a dermatologist regularly for acne, and they offered Accutane after trying various creams. I had normal hormonal acne, not cystic acne. But I do remember feeling super self-conscious of it. [The Accutane] worked quickly. The biggest disclaimer my derm shared was not to get pregnant or there would be serious birth defects and the child would not survive. Most people have to be on birth control, but my dermatologist let me sign a form of celibacy. Not drinking alcohol was a big disclaimer as well. I had to get blood work once a month. Two years later, I started having symptoms of estrogen dominance. My primary doctor noted that my liver could not properly break down estrogen, causing a slew of issues for me. With diet and supplements, I was able to support my liver. But years later, after I stopped using supplements, had changes in my diet, and experienced some stressful life events, my estrogen dominance is back. By the time these connections were made, I was no longer treated by the dermatologist who prescribed me Accutane. Now, I see a nutritionist, and when discussing my recent bloodwork (and high retinol levels), they asked me if I ever took Accutane and confirmed that it can disrupt liver function.” – Gabriella, New York

It boosted my self-esteem, but be prepared to really take care of yourself.

“I started taking Accutane because I had cystic acne all over my face and chest, and worried I wouldn’t be taken seriously as a makeup artist. It dramatically cleared things up and boosted my self-esteem. But I had to take very good care of myself while I was on it, and some of the side effects still linger years later. I still have stomach problems because of it and some joint issues with my knees.

“My skin was so sensitive to the sun and basically anything harsh. I couldn’t get waxed for six months after taking it. I had to stay very hydrated. I couldn’t take supplements. Aquaphor was my best friend — I layered it on my face and lips throughout the day. I usually have an oily scalp and hair, but my hair became really dry, so I couldn’t wash it as frequently — maybe just once a week. I would layer on hair masks, double condition, and use lots of oils and stuff.

“The added skin sensitivity made me have allergic reactions to adhesive. I couldn’t use fake eyelashes or Band-Aids. You can’t get tattoos while taking it. Anything with red pigment, like red lipstick, would have intense reactions. My eyes became very dry and sensitive too. I would get styes around my eyelash line and under my eyelid. I had to have an eye cleansing protocol with wipes, eye drops, and a heated compress.

“Also, I had to get my blood drawn every month to make sure my vitals were OK, I had to take two kinds of birth control, and I couldn’t drink while on it (since it can be harsh on your liver). Basically, you have to be prepared to really take care of yourself while taking it. It’s a commitment.” – Jenna Kristina, Los Angeles

I experienced depression and suicidality. (To be fair, I took it while drinking.)

“I took Accutane for about two to three months when I was 20. I had giant, painful zits on my nose and cheeks. My mom and my brother took Accutane, and they were fine. But when I took it, not so much. To be fair, at the time I was partying, drinking, and smoking… and you’re not supposed to do that while taking Accutane. The first few weeks in, my skin started to dry out, but the acne didn’t really clear up. I would get these painful, itchy rashes on the back of my hands and up my arms. I remember the doctor saying that depression and suicidal thoughts were potential symptoms, but it was said kind of casually. I thought, That’s not going to happen to me. Pretty quickly after I started taking the prescription, I had vivid suicidal thoughts. It came on suddenly and it felt totally justified in my mind — which felt very different than who I normally was. I couldn’t focus on school or work. I didn’t know what was happening to me. Now that I’m older, I can look back and say, ‘Oh, I was depressed.’ I soon realized that the Accutane wasn’t working and that it was possibly causing the dark thoughts and urges, so I decided to not take it anymore. When I stopped taking it, the rashes cleared up, and I started to feel like myself again.” – Chris, New York

Are There Alternatives To Accutane?

Yes and no. “While there are a host of acne treatments out there, to my knowledge there is no drug for acne that is as effective as isotretinoin,” Landriscina says. “It is the only treatment we have that can put acne into remission for long periods of time without continued treatment.”

Rossi agrees that isotretinoin is the gold standard for nodulocystic acne and scarring acne, but explains that “alternative treatments include other oral medications and even light-based therapy such as photodynamic therapy, or lasers.”

“You can get acne better with alternatives but not cure it,” Eldik elaborates. “Choices are oral antibiotics, DHT-blockers like spironolactone, topical antibiotics, topical hormonal blockers, topical retinoids, cleansers with actives in it like sulfur, salicylic acid, and benzoyl peroxide, or blu-light, an in-office procedure that kills the bacteria responsible for creating acne. The MMSkincare MMSphere 2GO also has a powerful blue light setting that kills acne bacteria and was created for at home use. Chemical peels are also effective.”

For a more holistic approach, Nazarian explains that some people have success with oral niacinamide (a version of vitamin D3, which is a naturally anti-inflammatory antioxidant), topical vitamin A derivatives (like retinol or tretinoin), or even alternatives such as bakuchiol. “Studies have shown that spearmint tea can be used with some degree of success, for people looking for alternative options to traditional medicine,” she adds. “My recommendation is always to discuss your options with your board-certified dermatologist, weighing all the risks and benefits, and considering your comfort level on all treatments.”

The Takeaway

No matter what road you decided to take in your acne journey, it’s clear that Accutane isn’t a casual drug that should be taken at the slightest hint of a breakout. In fact, given all of the side effects — both mental and physical — it should be something you discuss as an option in-depth with your dermatologist and those close to you, knowing that it can wreak havoc on your body. But there’s no denying the power it has to change someone’s skin for the better — and in many cases, it might be the only thing that works. The best thing you can do is arm yourself with all the information available, so you can make the decision that’s best for you, your skin, and your body.

Studies:

Bettoli V, Guerra-Tapia A, Herane MI, Piquero-Martín J. Challenges and Solutions in Oral Isotretinoin in Acne: Reflections on 35 Years of Experience. Clinical, Cosmetic and Investigational Dermatology. 2019 Dec 30

Fouladgar N, Khabazkhoob M, Hanifnia AR, Yekta A, Mirzajani A. Evaluation of the effects of isotretinoin for treatment of acne on corneal sensitivity. Journal of Current Ophthalmology. 2018 Sep 6