The cutting remark was flung at her more than a year ago, but it still stings in Caitlin Devor's ears as clearly -- and painfully -- as if it happened yesterday.

	Matt Freed, Post-Gazette Caitlin Devor, 13, of Pine was treated with Accutane for her severe acne. Click photo for larger image. Related articles One teen's experience using Accutane Acne causes, Accutane effects Internet information Food and Drug Administration www.fda.gov (search for Accutane) Roche Pharmaceuticals www.rocheusa.com

A seventh-grader at Pine-Richland Middle School at the time, Caitlin was standing up on the school bus, looking for a seat, when a shout came up from the back.

"Hey, zit down!"

Had she had just a pimple or two, the youngster probably would have shrugged off the comment. Only she didn't. Covered with the angry-looking, fluid-filled sores that characterize severe nodular cystic acne, her face was about as bad as a teenager's could get.

"That hurt," Caitlin says, her voice softening at the memory.

The middle schooler, whose acne first appeared at age 11, might have continued to suffer in silence had her dermatologist a year later not prescribed the powerful but controversial drug isotretinoin, most commonly known as Accutane. A member of a class of drugs known as retinoids, a form of vitamin A, it is the most effective therapy available for severe acne.

It changed Caitlin's life. During a five-month treatment, her acne almost disappeared, save for a tiny dry spot on the bridge of her nose. Or as Caitlin, now 13, puts it, "There's none of those ugly red dots all over my face. It's clear, the way skin is supposed to be."

Still, it wasn't an easy decision for her mother, Catherine, who was all too aware of the drug's imposing (and scary) list of potential side affects.

Like other retinoids, the Roche Pharmaceuticals drug works by making changes in how proteins are produced in cells, but its exact mechanism of action is not known. Accutane shrinks the size and output of oil glands in the skin and stops the follicles from getting plugged and the bacteria from growing. It also curbs the inflammation that turns into the unsightly blemishes.

But the drug also can cause a variety of side effects ranging from the less severe dry skin and chapped lips to brain swelling and severe headaches, liver damage, birth defects and major depression.

"This is pretty serious stuff," says Douglas Kress, a dermatologist at Children's Hospital.

Yet despite the risks, more than 9 million prescriptions of Accutane have been written since the drug came on the market in the early 1980s, says Kress. And as generic versions get cheaper and more health plans agree to pay for it, that number will grow.

The most serious side effect is the risk of severe birth defects, as well as miscarriage and premature births. The possibility is so high that female patients -- including young teens who have begun menstruating -- can get the drug only after they've had two negative pregnancy tests, even if the patient (or her mother) swears she's not sexually active. And because all forms of birth control can fail, other than sterilization and a hysterectomy, they must also verify that they're using two separate forms of birth control at the same time.

But what has grabbed most of the media attention is the drug's suspected link to depression, psychosis and, in extremely rare cases, suicide. The Food and Drug Administration has received reports of more than 30 suicides by Accutane users since the it was approved in 1982, leading to several groups' attempts to get the drug banned and a call for stricter safety controls. (Remember the Florida teenager who killed himself two years ago by crashing a plane into a Tampa skyscraper? His family claims Accutane caused him to become severely psychotic, and has filed a $70 million lawsuit against Roche.) In 1998, the FDA advised doctors who prescribe Accutane to watch their patients for signs of depression.

Jon Schoenberger of Point Breeze is a case in point. Now a freshman at Indiana University of Pennsylvania, the 19-year-old got so depressed after beginning Accutane treatments a year ago that he had to leave school and go to Western Psychiatric Institute and Clinic for a psychological evaluation. His dermatologist immediately took him off the medication.

While he was never suicidal, "I just didn't feel right," says Schoenberger, who noticed the affects just a little over a month into his treatment. "I couldn't do any work and I was just sad constantly. It's like I was alone in the world and the days were darker."

"He was extremely worried and self-conscious," agrees his mother, Polly McQueen.

Once the drug was out of his system, Schoenberger returned to his old self and today keeps his acne, which first appeared in seventh grade, under control with Clinique products. But the experience left both him and his mother a bit rattled.

"I might listen a little harder when a doctor talks about serious side affects," McQueen says.

"It's intimidating," concedes Dr. Melanie Costa, Caitlin's dermatologist. "I spend half of my time trying to talk people out of it and half of my time trying to talk them into it."

As a result, most doctors reserve the medication for severe nodular cystic acne that has not responded to any other treatment. That includes topical antibiotics like erythromycin, topical retinoids like Retin-A or oral antibiotics like tetracycline.

Caitlin spent 18 months on other treatments before trying Accutane. Her mother, though, who had cystic acne as a teenager, felt the risk was worth taking.

"I didn't want her to go through what I went through, with all the feelings of inadequacy and not feeling pretty," she says. "Girls at this age are very self-conscious. If they have severe acne, that's one more obstacle to get over."

And it's not being used just by teenagers. Heather Cook of Fombell, a 32-year-old mother of two, is among the large number of adults who has been helped by the medication. She turned to Accutane last July after a variety of topical and oral treatments failed to control the cystic acne that had plagued her neck and chin since high school. "I kept thinking I would grow out of it, but I never did, even after having children," says Cook, who wore makeup and turtlenecks to hide the blemishes.

Her face started to clear in a few months and today is virtually blemish-free. The only side affect, she says, was extremely dry lips.

"It's unbelievable," she says. "My skin is perfect. Now when I go out, I don't even have to put on makeup."

But the best part is that her acne shouldn't come back. Sixty to 70 percent of patients are cured, says Kress, the Pitt dermatologist.

As for the increased risk of depression and suicide, some experts argue it's hard to definitively link it directly to the use of Accutane, because severe acne in itself can lead to anxiety, compromised self-esteem and feelings of despair. Some studies, in fact, have shown that successful treatment of acne can actually decrease social anxiety and depression.

"For most patients, it's a miracle drug," Kress says. "My happiest patients ever are those on Accutane, even more than those who get melanomas cut out. Their smiles are from ear to ear."

Costa also calls Accutane one of the "most rewarding" medications she uses. Caitlin Devor agrees.

For the first time in a long time, she says, she's not depressed or stressed out by her appearance.

"I even like looking in the mirror."