Doctors often like to combine spiro with another medication to attack acne on all fronts. “One of the best studies I’ve seen shows an excellent response when women take spiro and Yaz [the birth-control pill],” Dr. Chernoff says. Your doctor might also suggest a topical retinoid, like Retin-A, or a benzoyl peroxide treatment, she explains.

The counterpoint is the intense, but short-treatment period with isotretinoin. Treatment tends to last four to six months and requires monthly visits to your dermatologist, blood work (to test for liver function, cholesterol levels, and pregnancy), and compliance with the iPledge program, which involves taking monthly quizzes that prove you understand the side effects of the drug. Plus, doctors often advise avoiding alcohol during treatment.

Doctors have seen some instances in which the first dose of isotretinoin causes an acne flare-up, Dr. Chernoff says. To avoid that, you might take a low dose for the first month and then increase to a full dose after that. And depending on your results, your dermatologist might extend your treatment to nine months. “There has been some newer data that says using the treatment longer extends the length of time before a relapse may occur,” she says.

While you're taking isotretinoin, your doctor won’t use any other topicals or prescription treatments since the drug addresses all the acne-causing variables. You’ll just need to moisturize more than you ever have in your life and spend lots of quality time with your doctor.

How Your Doctor Decides Which To Prescribe

The decision is about the type of acne the patient has and how likely they are to follow the prescribed treatment, Dr. Holcomb says. “I really base my choice on whether a patient wants to take a pill every day for an indefinite amount of time or a finite amount of time,” she says. Again, spiro is a long-term solution, while isotretinoin requires a few months of treatment.

“A lot of the decision is patient preference,” Dr. Chernoff says. “Many women are worried about the side effects of isotretinoin, and spiro is easier to tolerate.”

For acne that’s focused on the center of the face, or appears as large cysts that have the potential to scar, dermatologists tend to prefer isotretinoin. “I find isotretinoin can be a lifesaver [for those at risk for] severe scarring — we want to stop the cycle as soon as possible.”

Either way, these proven treatments offer a way to escape the frustrating breakout cycle. “Spironolactone and isotretinoin are two of the most important drugs we have to treat acne, particularly in women unresponsive to topical treatments,” Dr. Zeichner says. So if you've tried it all and still aren't seeing results, maybe it's time to give one of these take-no-prisoners treatments a shot.