PROLOGUE

It started at fourteen, a cluster of tiny pimples in the center of my forehead, a third eye. My mother bought me Clearasil wash and Stridex pads and Oxy cream. None of it worked. Mysteriously, the patch cleared up in a few months, establishing a pattern that would go on for the rest of my life: awkward acne, resistant to treatment, that eventually cleared up for no apparent reason.

Then I turned 30. Suddenly the acne was persistent, no longer limited to my face, consistently covering my back, often my chest. This is somewhat common for many women: changing hormones, the body saying Hurry the fuck up and breed. I tried more creams, more washes, antibiotics, hormone blockers, supplements, a change in diet. Nothing worked. There was one option left.

Isotretinoin, commonly referred to as Accutane, is the only proven cure for acne. I’d toyed with taking it before but concluded my acne wasn’t bad enough to account for the risks. It’s an extreme medication, essentially poisoning the body with Vitamin A, the side effects numerous and severe. Chapped, flaky lips are a guarantee. It is likely your skin will experience the same. Other possibilities include excessive thirst, greater sensitivity to sunlight, hair loss, nosebleeds, rashes. And then there are the extremes, things like developing Crohn’s disease, permanent muscle or eye damage, or death. But the effects that scare me most: depression, suicidality, psychosis.

I have bipolar disorder, type 1, the most severe kind. I oscillated through depression for years, attempted suicide four times, have been officially psychotic twice. These are facts. It took most of my life to get stable, through tons of therapy and psychiatric medication. So now, it seems stupid to potentially give up all this hard work to get rid of moderate acne, but my psychiatrist and dermatologist aren’t concerned. I’m so sick of the acne, so sick of being made insecure by something so objectively stupid and small, that finally I decide to risk it. I will do it. I will go nuclear.

BIRTH DEFECTS

Anyone who wants to get on Accutane is required to sign a page-long release, initialing here and here that you understand the side effects. And if you are a woman capable of childbearing who admits to having sex with men, you also get to initial a second page-long form, which contains diagrams of babies with elongated heads and haughty faces.

Then you get sent home with an illustrated book that goes into detail about birth defects and birth control. You have to agree to two separate types of birth control. I have a copper IUD, 99.9 percent effective, and no moral reservations when it comes to abortion, so I lie and claim I’ll also use male latex condoms. Every month, I will take a pregnancy blood test, wait for the results, and then answer a short yet tedious quiz about birth control. From there, I have exactly seven days to fill the prescription; otherwise, I’ll have to begin the process again.

HOMEWORK

I spend hours reading acne forums, Reddit threads, and beauty articles about Accutane. I even go through academic journals, charts and numbers about effectiveness and risks and dosage. The day I get my prescription, I deploy the arsenal of moisturizing products I’ve been storing up since I initially decided to go on Accutane.

I learn there is something inherently different about buying beauty products when the goal is to hydrate rather than deslick. With acne products, it is implicit that you are gross; you need to get rid of the oils bubbling out of your body. But hydrating products are there to add, not subtract, making me feel like I soon will be fragile and delicate. Even the color schemes of the products are different: instead of sickly oranges and greens, the packages come in hues of aqua and rose.

KAFKAESQUE

Despite my preparation, I’m not able to pick up my prescription right away, because of my insurance. In order for my insurance to be approved, I have to go through an insane amount of bureaucracy. This is the order:

  1. Go to the doctor
  2. Take a pregnancy test, get a prescription
  3. Wait a day
  4. Call the doctor, who confirms you’re not pregnant
  5. Login to iPledge, a website where you take the short yet tedious quiz
  6. Drop off the prescription at the pharmacy
  7. Wait while the pharmacy calls the doctor
  8. Wait while the pharmacy determines you’ve completed the iPledge quiz
  9. Wait while the pharmacy faxes your insurance
  10. Wait while the insurance company contacts something called CareMark
  11. Wait while CareMark calls something called (ironically) Rational Drug Therapy (RDT)
  12. Wait, up to 72 hours, while RDT decides whether or not to approve your prescription

I wait six days, growing increasingly anxious, calling the doctor and the pharmacy and my insurance company, trying to figure out what is holding things up. Eventually, someone tells me about the final step, that I am waiting for Rational Drug Therapy. Patients are not allowed to call RDT. Neither are doctors or pharmacies. I am in (Ir)Rational Limbo.

I track down a phone number for RDT. Both the website and phone number inform me I’m not allowed to call them. I ignore this, hold the line, get a human. She explains I’m not allowed to call, but I don’t stop talking until she reluctantly agrees to approve my prescription. But by then, the business day is over, and my prescription has turned into a pumpkin.

PURGE

The first ten days on Accutane, nothing happens. On the eleventh, my skin dries up. It isn’t gradual — one day my skin is oily and disgusting, and the next it is paper dry. My lips, as promised, are especially dry, and I find myself constantly applying lip balm. Strange flaky bits of skin appear at the corners of my mouth, thick in the mornings, and I discover that I have to be careful when removing them, unless I want my mouth to bleed. I wait, nervously, for the thing so horrible that the forums have granted it an acronym, IBO, initial breakout, reportedly the worst breakout of your life. But I am lucky. Three weeks in, my face becomes covered with thousands of tiny whiteheads. My chest and back look like they’re coated in a thin layer of dust, some strange variant of blackheads. My skin stays this way for a couple of weeks, but once this is gone, my skin is clear. It feels miraculous.

WARNING

There are some minor scares. I take the medicine for a couple of days and decide to check Crazymeds, this generally helpful website that has user-generated information about psych meds. I want to read about other bipolar people who’ve been on Accutane. I find a post by a woman who says she is bipolar and that Accutane made her break her neck and nearly become paralyzed. The woman doesn’t explain how this happened, what being bipolar has to do with it. It makes literally no sense. But the fear worms its way into my brain anyway. I sit very straight. I pay attention to the subtle pain in my muscles, perhaps imagined. I do not move my neck. It takes several days for the fear to go away.

A few weeks later, I am home alone for the night, my husband at his parents’ house an hour away. I take a shower. I get out. While drying off, I notice the veins in my arms and legs, neon blue webbing across my hands and feet, sticking out, throbbing, this overwhelming knowledge that there are miles of tunnels in my body, forever pulsing blood. I look in the mirror, notice veins I’ve never seen before in my eyelids, the thick snake down my throat. They all hurt. I run through the possibilities. My veins might … pop out of … my skin? Is this possible? I consult Google. Of course it isn’t. I remember one of the conflicting things I read in my hours of research, that Accutane makes the skin thinner by something like three cells. My veins have always been pronounced, praised every time I’ve had my blood taken. It’s just those three cells, the hot water, everything is fine, it is not possible for veins to pop out of the body. Still, for the rest of the night, I remain vigilant, looking at my veins, making sure they’re not separating from or piercing my skin.

THE TURN

In the fourth month, I realize something. I am depressed. It’s late summer and I’m a teacher, so originally I dismiss it: Things will get better once school starts. But school begins and things are worse. It finally hits me. It’s the Accutane.

I am reluctant to quit. It is believed that the efficacy is based on the cumulative dose: the general rule is 120–150 mg/kg. As someone who weighs 60 kg, I need to take Accutane for six months. I go back to the scholarly journals to see how likely a relapse would be. I find studies suggesting that the medication is effective at a much lower dose — about half what the older studies recommend. But as I comb through the numbers, I read the relapse rate is sometimes as high as 50 percent, a much different percentage to a scientist than to someone who has suffered from acne for decades. I don’t want to relapse. I’ve come this far. I can go a couple more months.

When I see the dermatologist, he becomes very nervous once I say I’m depressed. He seems less alarmed when I assure him I’m not suicidal and that the depression is more annoying than dangerous.

I fail to mention, though, the time I was driving home from work and had to resist plowing my car into the concrete divider. I fail to mention how this reminds me of the time I was on antidepressants, when I was constantly followed by visions of my death — slashed wrists in a grocery store, car crashes, drownings. That time ended in a hospital. I’ve learned from experience this is not the type of thing you should say to a doctor unless absolutely necessary, which it isn’t. I know what is causing my depression. I know not to act on it. I just have to use my coping mechanisms, the things I picked up in the decades of therapy: write, exercise, take baths. I tell the doctor this. He gives me another prescription.

The next month, though. One day, I wake up so depressed I can barely move. I remember this feeling. The last time I felt it was in college, a complete indifference to everything, as though the entire world has been turned down until all of it is meaningless and flat. I can’t write, or go to the gym, or do anything else to make myself feel better. It’s impossible. The only things that don’t make me want to die are watching old seasons of Project Runway and playing Bubble Witch 3, so I do this for hours and then days. My husband catches me staring off into space, a look of doom on my face, finding me stomach-down on the floor. I imagine this continuing for the rest of my treatment. I can’t.

I go back to the database and read more literature. I read how it is unlikely but “statistically significant” that Accutane will cause depression — in around 3 percent of patients. I also learn that this is heightened if the patient is “predisposed to depression.” I want to laugh, but of course I don’t, because I’m too depressed to laugh. I pull out a calculator, figure out I’ll have to be on Accutane for fifteen more days to reach 120 mg/kg, that magic number. I can’t do it. I don’t care if I relapse.

A few days off it, and I am able to do more than stare off into space and watch Project Runway. A few days more, and I am back to laughing, back to no longer feeling crazy. My skin stays clear and not greasy, although I have nightmares where the acne has come back. In the morning, I run my fingers over my face, relieved and basking in its smoothness. It seems sick to me that I consider the depression worth it, but I do. I’d suffer through all of this, if I had to, again.

Juliet Escoria is the author of Witch Hunt (Lazy Fascist, 2016) and Black Cloud (CCM/Emily Books, 2014). She lives in West Virginia.