A dermatologist once described Accutane to me as a drug that "damages the oil glands so they no longer produce oil." No oil, no acne, right? Well, kind of, but that's a bit like amputating your arm to fix a broken bone. It's like torching the planet to put a stop to climate change. What Accutane really does to your skin is like, well, destroying it in the name of saving it.
To back up a bit: Accutane is formally known as isotretinoin, an isolated vitamin A derivative that has been prescribed to millions of acne patients in the U.S. since its initial FDA approval in 1982. (It's also marketed as Roaccutane, Claravis, Myorisan, Absorica, Zenatane, and Amnesteem.) "Despite the fact that it is derived from a vitamin, this medication and dose is not found naturally," Dr. Rajani Katta, the author of Glow: The Dermatologist's Guide to a Whole Foods Younger Skin Diet, tells NYLON.
The substance has come under scrutiny for its side effects, which are alarming if infrequent: depression, rectal bleeding, seizures, anemia, and increased blood cholesterol, to name just a few of the hundred or so possibilities that appear on isotretinoin's official Rx warning. Some studies have linked it to a higher risk of developing inflammatory bowel disease, though this link has not yet been definitively proven. Its impact on the reproductive system — birth defects, spontaneous abortion — is so severe that patients with a vagina are required to pledge to use two forms of birth control while on isotretinoin, and submit to monthly blood and pregnancy tests, just to be safe.
Yet, for all the criticism thrown its way, isotretinoin catches a similar amount of praise. Beauty editors and influencers are quick to downplay its risks and revel in the rewards of a pimple-free face. It is the most reliable acne-fighting drug at dermatologists' disposal, with a 80%+ "success" rate and more than $1 billion per year in profits. Simply put, the stuff works.
How Does Accutane Work?
"Isotretinoin helps to reduce oil production on the skin, and actually helps to reduce the size of the sebaceous glands, which are the glands in the skin that produce sebum," Dr. Katta explains. The sebaceous glands are part of the body's exocrine system, FYI, and sebum is a fancy word for the skin's natural oil.
Dr. Aanand Geria, a board-certified dermatologist with Geria Dermatology in New Jersey, puts it a little less delicately: It seems that isotretinoin makes your "oil gland cells self-destruct."
The absence of sufficient sebum is responsible for isotretinoin's less serious but exceedingly common side effects, including "dry eyes, dry lips, and very dry skin," says Dr. Katta, which nearly 100% of patients experience. "I've even had some patients develop eczema with dry, cracked skin." Most are OK with trading acne for extreme dryness, though, assuming the dryness will end when treatment does. But for some — like me, a decade post-Accutane and still struggling with moisture-starved and acne-prone skin — these symptoms stick around.
Although dermatologists maintain that the sebaceous glands bounce back eventually, research shows still-inhibited sebum production in patients at two months, one year, and 12 years after isotretinoin treatment; one study called dry skin, dry eye, and eczema "probable long-term side-effects." Which is sad, really.
Sebum By Itself Does Not Cause Acne
"Sebum is a vital component of normal, healthy skin," Dr. Geria agrees. It's the body's built-in moisturizer, responsible for locking in hydration. It is integral to the acid mantle, a thin layer of the skin barrier that helps neutralize invading pathogens and stabilize the skin's pH level. Sebum has "innate antibacterial activity" and can even have an anti-inflammatory effect on the skin. It is essential to the skin's wound-healing response, and it acts as a natural sun protector, too. Sebum is one of the most magical and precious skin care products in existence, and it comes out of your own pores.
So how did it get such a bad rap? It's complicated. Sebum is involved in the proliferation of acne, but to borrow one of science's favorite sayings, "correlation does not equal causation." Sebum only contributes to acne if other factors are at play. (Think of it this way: "Oily" and "acne-prone" are two different skin types, right?) So, yes, eliminating oil production with isotretinoin may consequently curb acne… but it does nothing to address the reason acne is present in the first place. This explains why around 23% of isotretinoin patients — the ones whose sebaceous glands do rebound — need two or more courses of treatment to see "results." The root issue is still wreaking havoc.
"A lot of what I see with Accutane is people who come in four, five, six years after the fact and still have acne," Jessica Cogan, a holistic healthcare practitioner in Los Angeles who focuses on skin care and autoimmunity, tells NYLON. "Some have taken Accutane three or four times. If that's not an example of [isotretinoin] being a Band-Aid for what's actually wrong, I don't know what is."
The root cause or causes will differ from person to person, but the big one is hormonal imbalance. Sebum production is stimulated by testosterone and the "stress hormone" cortisol. An excess of either can lead to excess sebum, which can lead to clogged pores, which can lead to acne. In this sense, hormonal breakouts act as communications from the body ("We're imbalanced in here!"), and when you silence the sebaceous glands, you cut off that communication — at least temporarily. In patients whose acne was determined to be hormonal, "complete remission could not be obtained" with isotretinoin, one study found.
There are plenty of other acne instigators: low linoleic acid levels (which can thicken sebum and lead to clogged pores), diet (sugar and dairy can cause acne, but so can "healthy" foods, if your unique body is sensitive to them), an impaired microbiome (in your gut or on your skin), not getting enough vitamin D, the overuse of skin care products, the overuse of harsh skin care products, immune response, intolerances, and more. But you know what's not on that list, and will never be on that list? Sebum.
Here's where you may be wondering, "If sebum don't cause acne, how come sebum-zapping isotretinoin is considered the gold standard in acne treatment?" Well, first, refer to that $1 billion in profits thing. But on a less capitalist-conspiracy-theory level, it's because sebum is the single common denominator across all of the acne triggers above.
The Issue? Sebum Is The Common Denominator
"I have a ton of post-Accutane clients whose skin is so damaged and so dry and so prematurely aged because their face isn't naturally hydrating, and they have to work so much harder to balance out their skin, because their skin has lost its natural function," Cogan says. "I have post-Accutane clients who are breaking out again and have the same sebaceous gland damage, so we have to deal with the acne and the damage. Then I have the post-Accutane clients who are just chronically dry."
Many of these patients, Cogan says, feel duped. Isotretinoin merely replaced one chronic skin condition with another; one that's arguably more difficult to deal with. After all, there's no un-destructing a fully self-destructed sebaceous gland — but with time, trial, and error, it is possible to heal acne holistically. (As for how, I'd need an entire book, but The Acne Answer is a good place to start.)
Of course, it's important to note that it can take months or even years to properly address the root cause(s) of your acne. "I went to the dermatologist the other day for a mole check and he said, 'Oh my god, did you take Accutane, your skin looks amazing,'" Cogan recalls. "I was like, 'Thank you so much, no, I've been on a six year acne healing journey.'" The practitioner says that though she's grateful for her own long, winding path to a clear complexion, taking isotretinoin "would've been so much easier, and would've saved me some deep, psychological scarring, so I understand why people go that way."
I understand, too; that's precisely why I agreed to Accutane 10 years ago. Acne anxiety — the intense shame, the feeling of unworthiness, the avoidance of mirrors at all costs — had taken over my life, and dermatologists told me this was my only option.
I wouldn't do it again, and Dr. Geria perfectly sums up why: "We need to change our attitude toward sebum, because vilifying it almost always makes skin worse in the long run."
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Dr. Rajani Katta, the author of Glow: The Dermatologist's Guide to a Whole Foods Younger Skin Diet
Dr. Aanand Geria, board-certified dermatologist with Geria Dermatology
Jessica Cogan, holistic healthcare practitioner in Los Angeles