Used properly, isotretinoin is safe and produces few side effects beyond dry lips and occasional muscle aches. This drug is prescribed for five to six months. Fasting blood tests are monitored monthly to check liver function and the level of triglycerides, relatives of cholesterol which often rise a bit during treatment, but rarely to the point where treatment has to be modified or stopped.

Even though isotretinoin does not remain the body after therapy is stopped, improvement is often long-lasting. It is safe to take two or three courses of the drug if unresponsive acne makes a comeback. It is, however, best to wait at least several months and to try other methods before using isotretinoin again.

Isotretinoin has a high risk of inducing birth defects if taken by pregnant women. Women of childbearing age who take isotretinoin need two negative pregnancy tests (blood or urine) before starting the drug, monthly tests while they take it, and another after they are done. Those who are sexually active must use two forms of contraception, one of which is usually the oral contraceptive pill. Isotretinoin leaves the body completely when treatment is done; women must be sure to avoid pregnancy for one month after therapy is stopped. There is, however, no risk to childbearing after that time.

Another concern, much discussed in the popular press, is the risk of depression and suicide in patients taking isotretinoin. Government oversight has resulted in a highly publicized and very burdensome national registration system for those taking the drug. This has reinforced concerns in many patients and their families have that isotretinoin is dangerous. In fact, large-scale studies so far have shown no increased risk for depression and suicide in those taking isotretinoin compared with the general population. Although it is important for those taking this drug to report mood changes (or any other symptoms) to their doctors, even patients who are being treated for depression are not barred from taking isotretinoin, whose striking success often improves the mood and outlook of patients who have suffered and been scarred by acne for years.

• Laser treatments: Recent years have brought reports of success in treating acne using lasers and similar devices, alone or in conjunction with photosensitizing dyes. It appears that these treatments are safe and can be effective, but it is not clear that their success is lasting. At this point, laser treatment of acne is best thought of as an adjunct to conventional therapy, rather than as a substitute.



• Chemical peels: Whether the superficial peels (like glycolic acid) performed by estheticians or deeper ones performed in the doctor's office, chemical peels are of modest, supportive benefit only, and in general, they do not substitute for regular therapy.
  
  



• Treatment of scars: For those patients whose acne has gone away but left them with permanent scarring, several options are available. These include surgical procedures to elevate deep, depressed scars and laser resurfacing to smooth out shallow scars. Newer forms of laser resurfacing ("fractional resurfacing") are less invasive and heal faster than older methods, although results are less complete and they may need to be repeated three or more times. These treatments can help, but they are never completely successful at eliminating scars.

How would you sum up current-day treatment of acne?

Treating acne requires patience and perseverance. Any of the treatments listed above may take two or three months to start working (even isotretinoin). Unless there are side effects such as dryness or allergy, it is important to give each regimen or drug enough time to work before giving up on it and moving on to other methods. Using modern methods, doctors can help clear up just about everyone.

Just hang in there. And don't pick. Please.