Hey Ugly,

I went to a dermatologist for the first time about a giant thing on my eyelid. It turned out to be a monster zit. Cute. She saw my severe acne scarring and prescribed spironolactone and Accutane. I have a shitload of acne scars and I’ve struggled with acne my entire life; I spent so much on vampire facials and topicals that didn’t work. In the past year I had reached a certain peace with it.

This doctor, however, made me feel like the goddamn Phantom of the Opera. I have a history of depression and suicidal ideation, so Accutane makes me nervous – the doctor brushed off my concerns – and I don’t love that spiro causes breast enlargement, because mine are big enough that I’ve considered a breast reduction.

What I’m asking is: should I just take the damn medication? Is this another gross incidence of beauty culture masquerading as health? Or am I ridiculous for spiraling?

– The Phantom

Phantom, I feel you. I once went to the emergency room for what I was pretty sure was a flesh-eating disease but turned out to be nothing more than an oozing, infected acne cluster. As you say: cute!

I guess I should’ve known. Pimples had taken over my face at puberty, and products took over my life not long after. That orange, oil-free acne wash. The cursed crushed walnut facial scrub. The Alicia Keys-endorsed Proactiv system. And when those didn’t do it? Prescriptions – so many prescriptions! Birth control pills to temper hormonal acne, antibiotics for the rest of it and, later, Accutane.

Having severe acne throughout my teens and 20s was agonizing, occasionally due to the pulsing pain of an under-the-skin cyst, but mostly due to beauty standards and social judgment. If only there were a pill for that. Pharmaceuticals did little to ameliorate this agony. My experience with them inspired my career in the beauty industry, actually. I wanted to understand what was happening to my skin, how these drugs were meant to work and why they didn’t really seem to stick.

Before I get going, a disclaimer: I am not a doctor! I will not give you doctor-like advice! You have that covered anyway. What follows is my personal take as a former patient and reporter.

Let’s start with whether you should “just take the damn medications”, Phantom: no. And to explain that answer, I have to first explain how skin works.

Skin does not exist to look pretty; it exists to protect. At its most basic, it’s a barrier that keeps the good stuff in (like blood and internal organs) and the bad stuff out (like disease-causing pathogens and pollutants). It interacts with your immune system, nervous system, your endocrine system, your muscular system, your digestive system – all the systems, pretty much. It stores fat and water. It’s home to the 1tn microorganisms of your microbiome. It regulates your body temperature so you don’t melt or freeze.

A lot of these functions are made possible by sebum, the oily substance produced in your pores. Sebum is the beauty industry’s go-to scapegoat for clogged pores – AKA, acne. Corporations manufacture cleansers to dissolve oil, devices to suck it, masks to strip it and medications to impede your ability to produce it. See: Accutane.

Accutane is the best known brand name for isotretinoin, an isolated vitamin A derivative that has been prescribed to millions of dermatology patients since 1982. It’s also on the market under various other branded names. It’s often spoken of as a last resort, and for good reason. The drug works by “damag[ing] the oil glands so they no longer produce oil”, a dermatologist once told me.

This is not ideal, considering the crucial role sebum plays in healthy skin function. It’s a little like slicing a pimple off your face with a steak knife – the offending spot is gone, sure, but at what cost?

Accutane did clear my skin for a while. But because sebum is not the root cause of acne, just an (unfairly demonized!) factor in its proliferation, my zits returned about a year later. My zapped sebaceous glands never really recovered either, so I’ve dealt with the downstream consequences of inadequate oil production for the past 18 years, including chronic dryness, sensitivity and inflammation.

I get your worries about depression and suicidal ideation. The US Food and Drug Administration issued a black box warning for isotretinoin in 2005, noting its links to suicide, depression, aggression and psychosis. But today, experts generally agree that isotretinoin does not increase these risks – which is probably why your derm brushed off your concerns – although the warning does remain on the Rx label.

Spironolactone functions differently. Originally prescribed for high blood pressure, it has the side effect of tamping down testosterone levels. This is useful for relieving surface symptoms of hormonal acne. It also has less-useful side effects, like breast pain or breast enlargement.

It’s effective as long as you’re taking it, but once you stop – which patients who are nursing, pregnant or trying to get pregnant must do – testosterone and breakouts can bounce back. The same thing happens with birth control pills, the hormonal acne solution I was prescribed at 15. Personally, I found it very frustrating to get off these meds and realize I didn’t know anything about my hormones or how to deal with them. I imagine it’d be doubly frustrating after buying a collection of brand-new bras to house your hormonally enhanced honkers.

Beyond that, I don’t see how spiro would be useful to you, specifically. It seems your only active zit at the time of prescription was on your eyelid, which is not an area of the face associated with hormonal acne (that honor belongs to the jawline and cheeks). Again, I’m not a doctor – you could ask a new dermatologist for a second opinion.

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Derms are people, of course, and people are conditioned by beauty culture. In my maybe-controversial view, many isotretinoin and spiro prescriptions could be critiqued as “beauty culture masquerading as health” – they seek to eliminate the surface symptom (skin aesthetic) without curiosity for the underlying cause (skin function).

I think pimples are sometimes to be expected and nothing to be ashamed of. But they can also point to deeper issues.

Skin has the mind-blowing ability to transform – into, say, itchy hives or a tender whitehead – so as to get your attention. Fun fact: the skin and the brain are formed from the same embryonic tissue in utero. Every eczema breakout or hormonal cyst is trying to tell you something, whether it’s, “You’re allergic to shrimp!” or “The air is dry!”

So it’s not superficial to consider what they might be saying.

For instance, consistently clogged pores could indicate a lack of vitamin D or Omega fatty acids, which both help make sebum less viscous. Persistent scars might point to a need for more of the nutrients involved in wound-healing and skin regeneration, like protein and vitamin C (essential for collagen production) or vitamin B3 (which supports the skin barrier). Bloodwork could help you suss out any vitamin deficiencies.

More from Jessica DeFino’s Ask Ugly:

• How do I deal with imperfection?

• How should I be styling my pubic hair?

• I’m mourning my old, ‘pretty’ self. Is this normal?

An endocrinologist can assess hormone levels and help determine if breakouts are part of a larger pattern. For instance, perhaps your period is irregular or you’re often fatigued – these other symptoms of hormone imbalance could be connected.

Some other things that helped me when acne prescriptions failed include drinking enough water, meditating daily and seriously cutting back on topical skincare. The basics are basics for a reason!

That said, you do not need to become Sherlock Holmes for every clogged pore. Do you go to the doctor or take medicine every time your stomach hurts? You probably say, “That was a lot of Domino’s” or something, and know you’ll feel better tomorrow. The same goes for skin.

Lastly: you are not ridiculous for spiraling. You had finally accepted your one, precious, ordinary human face! After years of injecting it with micro-sized syringes of centrifuged blood! That’s difficult – and then a medical professional dismissed your concerns and framed your appearance as a problem of pharmaceutical proportions. Ah, so goes the sisyphean task of existence.

We are proof that it’s possible to stop spiraling, though, even if you don’t stop getting pimples. I still break out sometimes. But now that I understand my skin (all the serious inner work probably helped too), I see spots as normal, not something to hide beneath a mask – opera, kaolin clay or otherwise.