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Sunday, October 23, 2022
Picking while on accutane.The Complete Accutane Before and After Guide: How to Get the Most Out of Your Acne Treatment
Is anyone on accutane and dealing with picking? | localhost.Accutane Before and After: 9 Women on Their Isotretinoin Side Effects
This level is very difficult to achieve for severe acne patients without isotretinoin and patients need to be educated to that reality. Many believe that there has to be something else that will get them these results, therefore, a breakdown of available treatments and expected results is often needed. If not, the patient may believe that you are just pushing one treatment option on them.
Accutane is also a good option. The patient may then offer up what they have heard about Accutane, negative or positive. Many will not say anything, which usually indicates they have not heard of it at all and need to know the basics.
Even if we convince them that this is the best treatment choice, and they agree, many will not return or will return wanting to try something else. We cannot and should not hold it against patients or look down on them that they have been exposed to misinformation that they accept it as fact. There are not experts. It is considered safe, very effective, and has never been withdrawn from the market in any country for safety concerns.
Within the dermatology community, it is not considered a controversial medication. Dermatologists are very comfortable with its use, so much so that many prescribe it to their own children or relatives I usually add here that my brother took it on my recommendation.
But the most important thing is that you have to be comfortable with it. If the patient wants to consider it as an option right then and there they will pursue that conversation, if not I pivot to other treatments. If the patient chooses other treatments, at least you have set the stage for more informative discussion down the road if they are not getting the results they want.
We have become very comfortable with using isotretinoin but must remember that for a patient, parent or teen, to consider taking a medication that is teratogenic and needs monitoring may just be too scary to consider, even if it is the only thing that will help. Often times our failure to navigate it and guide patients through it prevents patients from getting their medication.
Prescribers should not delegate iPLEDGE responsibilities to medical assistants without first mastering the system ourselves. For me this required several months of clearing people and making multiple calls to iPLEDGE, but it was a worthwhile investment. Going through this process, I concluded that it is unrealistic to expect a person with a medical assistant level education to master iPLEDGE on their own.
We have to register them and clear them every month but they do absolutely nothing. Whether these patients had blood tests is not a criteria for clearing them. They have a day window to pick up their medication. Registration cannot take place without a pregnancy test and even if the pregnancy test date precedes the registration date, the day window starts on the registration date.
This is why it is important to register patients the day the pregnancy test results come in to avoid delays. Schedule a four and a half to five week follow-up rather than four weeks follow-up for the second visit.
Two pregnancy tests must be taken more than 30 days apart. This means that if you schedule your female patient back for a one month follow up, they return 28 days later 4 weeks with their labs in hand that they took a few days beforehand,this is too early, and they have to re-take the pregnancy test after the 30 days window.
A four and a half to five week follow-up is ideal as it gives the patient enough time to get their next pregnancy test and labs. If female patients miss the seven day window to pick up their medication when they are getting their first prescription they have to wait at least 19 days to get another pregnancy test and pick up their prescription look at the patients calendar on iPLEDGE for the first date they can get another pregnancy test again.
For any prescription other than the first, if the seven day window is missed, all the patient has to do is take another pregnancy test, which immediately opens up another seven day window to get their medication. If the patient wants to choose abstinence as their primary form of birth control and condoms as the secondary form this is a red flag. When any of them is present, the following chain of events may occur:. The excess cells do not only grow fast, but they are also unusually sticky.
The hair follicle has limited room, so cellular overgrowth can easily clog your pores and make them swell from debris and oil buildup. It minimizes moisture loss from your skin and protects it from microbes and oxidative stress. Excess sebum production is often due to hormonally induced sebaceous gland dysfunction. The microbes and their waste products irritate the skin. All of the above changes lead to pressure buildup inside the hair follicle and subsequent inflammation.
The lesion can grow and rupture, causing acne. Hormonal changes make teenagers acne-prone, but the condition can afflict people of any age, including babies. BHSkin Dermatology physicians have a vast anti-acne arsenal , which includes the following:. Cleansing the skin twice daily minimizes impurities and oil buildup. Antibacterial cleansers inhibit bacterial growth. Cleansing is the gentlest approach to acne.
Topical medications like benzoyl peroxide, erythromycin and clindamycin have antimicrobial action. Some, like azelaic acid, can clear up your pores while getting rid of bacteria. Minocycline and clindamycin—two of the most commonly prescribed acne-busting antibiotics—also prevent oil accumulation in the skin. Some individuals are prone to hormonal acne or breakouts caused by androgen fluctuations. These patients may benefit from anti-androgenic medications.
Chocolate, milk, sweets, and fatty meals have all been implicated in breakouts, although the link between acne and food is not entirely clear. Still, adequate hydration and a healthy diet never hurt the skin, so we encourage our patients to make better food choices consistently.
UV radiation targets P. It boosts cell turnover to keep pores clear and 2. It reduces inflammation associated with breakouts. It's strong though, so use it only every three days for the first few months. For best results, apply it on clean skin for 10 minutes twice a week. BP is gold when it comes to killing acne-causing bacteria.
It's used here in a 2. Sofia Grahn isotretinoinwiths. Before Accutane, I used to have severe acne—mostly concentrated on my cheeks and forehead, but also along my neck, chest, and back. For the first month of treatment, my skin also went through the initial purging period, meaning my acne got significantly worse like, it doubled in severity before it started to calm down again.
Those first few months were percent the hardest to endure, but I look back at it all with gratitude. When my acne was at its peak severity, my mental health truly suffered in all ways imaginable.
So if my skin ever came to affect me the way it did prior to isotretinoin, I would probably go on it again. Before isotretinoin, I had severe cystic acne on my face, chest, arms, and back. Every time my skin bumped against something, it felt like somebody had poked the most sensitive blister. My acne would then form keloid scars , which I still have all over my shoulders and back. I decided to go on Accutane in the fall of I started with a low dosage twice a day, then was upped to a stronger dose once a day after a few months.
The strongest side effect I had was dry skin: My scalp and nose were always dry and itchy, and my lips were constantly cracked. The second side effect was a lower alcohol tolerance. I remember going out with friends early on in my Accutane journey, drinking just a few drinks, and getting a terrible hangover and headache that lasted way longer than my usual hangovers. Thankfully, these were my only two big side effects, and they went away on their own within two months after treatment.
Because my body tolerated Accutane so well and the results were so excellent, I finished after six months rather than the anticipated nine. I'm so happy I did it, and I wish I hadn't been so scared in the first place.
The best part is that my skin isn't constantly inflamed anymore—I can wear makeup, bras, and whatever clothes I want without being in constant pain. And now, whenever I do get the occasional pimple, I'm not worried that I'm about to face clusters of inflammation for months.
Not only does Accutane already put a bunch of stress on your liver which is the same organ responsible for processing all those White Claws you drink , but it also dries your body out.
I grew up in a beach town and would wear a full face of makeup to the beach, or beg not to go to school because I was having a particularly bad skin day. I ended up doing two rounds of isotretinoin about four years apart. Over time, though, my acne came back even worse and more painful than before, so I ended up doing a second round of treatment.
Hi guys, I found this site and was really happy, I always thought my picking came from mild OCD or something, it really makes me feel better seeing all of your stories and knowing that I am not alone. I have been picking for 15 years, i am 25 now. Its usally always on my face, popping pores, ripping scabs, pulling hairs out. I have wasted hundreds of hours sitting on the sink obsessing in the mirror.
My acne was always moderate in my teens but i still found ways to scar my body. In the last year and a half i have developed hormonal acne, maybe it wouldnt be so bad if i didnt pick, but i do. I can withhold for a couple days and my face will start to heal but eventually i will screw up and start the healing over.
I miss out on so much on life because I am embarrased of my skin. So, Dr. Schlessinger determined that some of my active acne was bacterial and put me on an antibiotic to clear it up. After a month with only small improvements, Dr. Schlessinger determined a more aggressive approach would provide the best result.
It was time to try Accutane. If you're considering Accutane, you might have a lot of the same questions I did.
Fortunately, thanks to Dr. Schlessinger, I now have the answers to these questions:. It is considered one of the most effective acne treatments on the market today. Accutane works by shrinking the sebaceous glands in the skin, which in turn reduces oil production.
When oil production is reduced, it prevents clogged pores that cause blemishes. The drug comes in pill form and must be taken one to two times daily for up to six months. The dosage and the length of time you take it is determined by your height and weight, which is why it must be prescribed by your doctor. Accutane is an excellent option for those struggling with active acne, cystic acne or acne scarring.
In my case, I had deep and persistent acne scars on my cheeks as a result of years of pimple popping and picking in my teens.
But, hey, I get it—you want details. Which is why I chatted with nine women about their before-and-after experiences with isotretinoin, from a few who finished their doses just a year ago, to some who finished theirs a decade ago, along with expert commentary from dermatologists.
Isotretinoin, commonly referred to as Accutane note: Accutane was a brand name for isotretinoin and is no longer manufacturedis a vitamin-A derivative that, when taken orally, minimizes the oil production in your skin. Basically, isotretinoin slowly shuts down the party in your pores, so acne has a hard time setting up shop on your face.
That being said, many patients tend to take mg of Accutane a day for six months —though, again, how many milligrams you take each day and for how long is based on your weight and health. For people with adult female acne AFAi. Again, it all super depends. Ideally, yes, Accutane is a permanent fix to major acne breakouts. But in reality, even the best-adhering patients can still get the occasional tiny zit because we're all human, and humans sometimes accidentally sleep in their makeupor stress out too much, or partake in a bit too many cocktailsthough they'll rarely experience acne as severely as before.
But does isotretinoin deserve the scary reputation you see on the internet? Definitely not except, of course, when we talk about its known risk of causing birth defectswhich is why regular blood tests, pregnancy tests, and birth control is required while taking the drug. But in terms of the other out-there side effects you hear about, I once polled a handful of dermatologists who, collectively, had written more than 2, isotretinoin prescriptions in their careers.
They said out of all their patients, fewer than 15 of them had serious problems while taking Accutane—the effects of which were resolved with a lower dose or stopping treatment altogether. Now, ready to get into those before-and-after photos and first-person stories? Thought so. Let's get into it:. Mariah Pearson mariah. A few months before I decided to start isotretinoin, I developed a very rare, very severe type of acne called acne conglobatawhich left my face covered in deep, itchy, leaky, and incredibly painful cysts.
It affected every aspect of my life, and I honestly felt like a victim to my own skin. I ended up going on isotretinoin for a little over eight months, and for the majority of that time, I was on 30mg: a lower dose than the usual mg, but the perfect dose for me. Thankfully, all of my side effects started to subside a month after I finished Accutaneand I noticed my energy levels rising after about two weeks.
I still have dry eyes nine months later, and I still break out before my period. Still, all of the side effects were so worth it to me, because isotretinoin saved my skin—it genuinely changed my life.
Another common, yet annoying side effect. My dermatologist ended up starting my Accutane dosage at 20mg the first month, then bumped me up to 40mg for three months, then had me on 60mg for the last two months. The only remaining side effect I have nine months after stopping Accutane is the eczema.
As for my acne, I do get the occasional cyst or whitehead now, though nowhere near as severely as before. I do feel really proud of myself for going on it despite my fears, though, and if I needed to, I would probably do it all over again. Infused with hyaluronic acid a humectant that draws moisture to the skinthis non-stripping face wash helps hydrate skin while you cleanse.
Slather on this moisturizing cream both morning and night to minimize dryness and flaking. The gentle formula is free from potential irritants, like synthetic fragrance and dyes. Any sunscreen is better than no sunscreen, but if your skin is red or sensitive, opt for a broad-spectrum mineral formula made with zinc like this one —it's less likely to irritate your skin.
When your lips are chapped and cracking, only Aquaphor will do. The combo of petroleum jelly, shea butter, and chamomile is intensely moisturizing and soothing.
Christina Yannello barefacedfemme. I got my first breakout when I was 12 years old, and for the next five years, I was in a constant battle with my skin. I tried everything under the sun to treat it: antibiotics, topical creams, chemical peels, veganism, hormonal pills, spironolactonecortisone shots, lasers—everything.
I was eventually diagnosed with polycystic ovary syndrome, or PCOS, a hormonal disorder that can cause—among other things—persistent acne. I knew then that I had to take the leap and try isotretinoin.
A post shared by bare faced femme barefacedfemme. I was on it for eight months total: For the first three months, I took 40mg, then 60mg for the last five months. I had dry everything —face, lips, eyes, scalp, body—and my hair started shedding a bit, too. It was all an emotional roller coaster for me. About two months after I finished Accutane, I saw the severity of my migraines, dry eyes, and dry scalp decrease.
After four months, my emotional health evened out and I felt back to my old self. It sounds weird, but I really think I was meant to get severe acne. My journey taught me so much about myself: to love myself and be confident, no matter the condition of my skin. And I would percent consider going back on isotretinoin again if I needed to. Belle Hubbard barefacedbelle. I suffered with severe acne for three years before deciding to try isotretinoin. My breakouts were super oily, sore, and red no matter what I put on them, and kids at school would call me Braille face.
The first two times, my acne slowly got worse over six months, then came back as bad as before. My dermatologist even switched up the dosing each time: My first course, I slowly reached 60mg a day; my second course, we took the approach of 10mg a day for a longer period of time; and my third course, I slowly reached 60mg again.
But after my third round, my skin was still incredibly oily and broken out. He apologized and said there was nothing else he could offer me. I cried the whole way home. But then, strangely, my skin began to clear up a few months later, almost like a delayed effect. A post shared by Belle all things positivity barefacedbelle. I honestly had almost every side effect in the book: dryness, eczema, rashes, body soreness, fatigue, blurred vision, headaches, nosebleeds, stomach problems, hair loss, irritability, and brain fog.
Even my vision was still a little blurry until this past summer. If you do decide to go on isotretinoin, I have two words of advice: 1 Take progress pictures! I tried to push myself over and over again, and I ended up worse off in the end.
Use this 2 percent salicylic acid serum all over or as a spot treatment to keep pores clear of acne-causing sebum and dead skin cells. This retinoid gel treats acne in two ways: 1.
It boosts cell turnover to keep pores clear and 2. It reduces inflammation associated with breakouts. It's strong though, so use it only every three days for the first few months. For best results, apply it on clean skin for 10 minutes twice a week. BP is gold when it comes to killing acne-causing bacteria. It's used here in a 2. Sofia Grahn isotretinoinwiths. Before Accutane, I used to have severe acne—mostly concentrated on my cheeks and forehead, but also along my neck, chest, and back.
For the first month of treatment, my skin also went through the initial purging period, meaning my acne got significantly worse like, it doubled in severity before it started to calm down again. Those first few months were percent the hardest to endure, but I look back at it all with gratitude. When my acne was at its peak severity, my mental health truly suffered in all ways imaginable.
So if my skin ever came to affect me the way it did prior to isotretinoin, I would probably go on it again. Before isotretinoin, I had severe cystic acne on my face, chest, arms, and back.
Every time my skin bumped against something, it felt like somebody had poked the most sensitive blister. My acne would then form keloid scarswhich I still have all over my shoulders and back. I decided to go on Accutane in the fall of I started with a low dosage twice a day, then was upped to a stronger dose once a day after a few months.
The strongest side effect I had was dry skin: My scalp and nose were always dry and itchy, and my lips were constantly cracked. The second side effect was a lower alcohol tolerance. I remember going out with friends early on in my Accutane journey, drinking just a few drinks, and getting a terrible hangover and headache that lasted way longer than my usual hangovers.
Thankfully, these were my only two big side effects, and they went away on their own within two months after treatment. Because my body tolerated Accutane so well and the results were so excellent, I finished after six months rather than the anticipated nine. I'm so happy I did it, and I wish I hadn't been so scared in the first place. The best part is that my skin isn't constantly inflamed anymore—I can wear makeup, bras, and whatever clothes I want without being in constant pain.
And now, whenever I do get the occasional pimple, I'm not worried that I'm about to face clusters of inflammation for months. Not only does Accutane already put a bunch of stress on your liver which is the same organ responsible for processing all those White Claws you drinkbut it also dries your body out. I grew up in a beach town and would wear a full face of makeup to the beach, or beg not to go to school because I was having a particularly bad skin day.
I ended up doing two rounds of isotretinoin about four years apart. Over time, though, my acne came back even worse and more painful than before, so I ended up doing a second round of treatment. I have no residual effects from the medication, and all of my deep acne scars have gone away, too. For me, the biggest side effects I dealt with were an extremely dry nose and lips, and I had large patches of cracked and scaly skin. But all of it started to go away within a few weeks after I finished the medication.
As Dr. Gohara said, very few five percent, if she had to guess of her patients go on Accutane a second time, while the vast majority never see a major breakout again. Again, your results will vary, but rest assured most patients see life-changing improvements with a course of isotretinoin.
localhost › Q&A › Accutane Questions. I have been picking for 15 years, i am 25 now. Its usally always on my face, popping pores, ripping scabs, pulling hairs out. I have wasted. For severe cases of acne, doctors often prescribe Isotretinoin, But while checking out my masterpiece in the mirror, I noticed a small. What products should I use while I'm on Accutane? scars on my cheeks as a result of years of pimple popping and picking in my teens. If you're thinking about starting an Accutane regimen, I'm sharing all the tips and tricks I picked up during my time on the drug. Hi there. The first two things listed are dry skin and dry lips with recommendations on specific products used to treat them and a list of other side effects arranged from most common to least common. Some may think that it causes suicidal thoughts, but there is no strong evidence connecting psychiatric illness to Accutane intake.Isotretinoin, the drug that revolutionized acne treatment, is the only medication that can clear acne and produce long-term remissions.
Since its introduction in , it continues to be a vital and widely used acne medication worldwide. It is used mainly for severe, recalcitrant nodulocystic acne as well as recalcitrant moderate acne. Abroad, isotretinoin tends to be dispensed more liberally than in the US and with a trend toward lower doses.
This article will not cover the well known pharmacology, dosing, and side effects of this medication. The goal is to have the patient very well educated and for the provider to have all the tools and knowledge to guide the patient through a successful treatment. Educating patients about isotretinoin and how it differs from other treatments is no easy task.
Isotretinoin is a unique drug and is completely different than any other acne medication. Below are the topics that are essential to cover during the patient visit and information on how I explain them to patients. Much of this information is included in the Isotretinoin Fact Sheet to be discussed later that I routinely hand out. Q: What is isotretinoin? Isotretinoin is a pill you take for four to five months. Your acne will start to improve in one to two months, and the vast majority of people are clear at the end of treatment.
It is the only acne medication that permanently reduces acne an average of 80 percent—some people a little more and some a little less. It also makes our skin less oily long-term. Twenty percent of patients take the medication a second time if they still have significant acne. Some blood tests are required.
After hearing so much about how effective isotretinoin is, patients expect dramatic results the first month and need to have their expectations managed. Temporary improvement vs. Isotretinoin is the only medication to produce a substantial permanent reduction in acne after you stop taking it. Isotretinoin is the only medication where these expectations can largely be met. For some people, it is quite a shock that at age 14 for example, without isotretinoin and sometimes with it if they do not get full clearance they will be treating their acne at least another five years.
This stark contrast between isotretinoin and non-isotretinoin treatment should be made crystal clear. How does it work? Isotretinoin works by shrinking your oil glands and normalizing the way your skin grows, which prevents pimples and clogged pores. Because your lips have a lot of oil glands they will become dry first, followed by your face and possibly other areas. Using lip balm frequently and moisturizing creams can manage these symptoms quite well.
You will also sunburn faster. We expect the medication to do this—this is how it works. Isotretinoin does not make scars or PIH post inflammatory hyperpigmentation , or post inflammatory erythema disappear. Some of the red marks and brown spots will clear up as your acne clears.
The scars will not be affected by isotretinoin. A few months after you finish treatment, we can see what red marks and brown marks remain, assess your scarring, and review your treatment options for clearing those up. Some treatments, like hydroquinone blend bleaching creams, can be initiated immediately after isotretinoin is finished or even during treatment if the skin can tolerate it. For some treatments lasers, chemical peels, etc. Initial flare is not therapeutic!
I f your acne gets worse in the first month or two, let us know so we can treat it! Initial flare is a common but preventable side effect. The more severe, inflammatory, widespread and cystic the acne is, the more common initial flare is. Strategies to prevent initial flare include lower initial dose and concurrent use of prednisone the first month.
Acne can also get worse the first month simply because all other acne medications have been discontinued and isotretinoin may take a month or two to begin working, causing a treatment gap. Keep in mind that non-drying topical medications can be continued as can spironolactone for female patients and any antibiotic except tetracyclines due to the increased risk of Pseudotumor Cerebri.
Take with food: Isotretinoin absorbs twice as well if you take it with meals. Isotretinoin is a lipophilic medication. One study showed 1. For the first few monthly follow-ups, I reinforce this important message of taking the medication with food. The easiest way to asses if the patient is a candidate for bid dosing is to ask if they have breakfast most days. If they do, ask what they eat. If it is a light meal or they do not regularly eat breakfast, stick with QD dosing.
Although the pharmacokinetics do favor twice daily dosing, if that causes more medication to be taken in the fasting state with poor absorption, it is counterproductive. In isotretinoin-Lidose Absorica came on the market promising higher absorption both in the fed and fasting states.
While it does have a marginal edge in the fed state vs generic isotretinoin keep in mind this was tested with the 1, calorie high fat meal, which very few people eat its real advantage is in the fasting state. Its fasting absorption is 68 percent versus the fed state. This was much better than standard isotretinoin, which only reached Over the course of treatment, poor absorption could lead to lower actual cumulative doses and higher relapse rates.
Patients with low fat diets or those who have irregular meal schedules benefit most from isotretinoin-Lidose. Birth defects: This medication can cause birth defects only while you are taking it and a month after, which is explained at the last visit but does not affect long-term fertility.
What this means is that if you become pregnant while taking it there are very strong odds of losing the baby or of serious birth defects. For this reason every female who is biologically capable of becoming pregnant must take monthly pregnancy tests and have a pregnancy prevention plan. Your colleagues will almost certainly offer positive feedback and praise for this drug.
Many have even prescribed it to their own children. However, when you discuss it with patients, a significant number have a negative opinion. How did this huge disconnect happen?
It would take an entire article to detail the history of the bad press isotretinoin has received. This creates significant challenges reconciling our views with what the patient has heard from non-expert sources. Great care must be taken when discussing isotretinoin as a treatment option, as it has a potential to alienate patients if not done properly. They report feeling overwhelmed and like they had little input and were not given all the treatment options.
Even if the patient is open to taking isotretinoin, it is easy to understand their concern taking a medication that requires monitoring and is teratogenic. The right approach is crucial. If our opinion is that isotretinoin is the only viable option, the conversation is straightforward. A new acne patient questionnaire is a great starting point. Isotretinoin is on that list listed as Accutane so patients recognize it. Some people circle it and some cross it out this does not necessarily mean they will never consider it, but expect resistance.
This level is very difficult to achieve for severe acne patients without isotretinoin and patients need to be educated to that reality. Many believe that there has to be something else that will get them these results, therefore, a breakdown of available treatments and expected results is often needed. If not, the patient may believe that you are just pushing one treatment option on them. Accutane is also a good option.
The patient may then offer up what they have heard about Accutane, negative or positive. Many will not say anything, which usually indicates they have not heard of it at all and need to know the basics. Even if we convince them that this is the best treatment choice, and they agree, many will not return or will return wanting to try something else. We cannot and should not hold it against patients or look down on them that they have been exposed to misinformation that they accept it as fact.
There are not experts. It is considered safe, very effective, and has never been withdrawn from the market in any country for safety concerns.
Within the dermatology community, it is not considered a controversial medication. Dermatologists are very comfortable with its use, so much so that many prescribe it to their own children or relatives I usually add here that my brother took it on my recommendation. But the most important thing is that you have to be comfortable with it. If the patient wants to consider it as an option right then and there they will pursue that conversation, if not I pivot to other treatments.
If the patient chooses other treatments, at least you have set the stage for more informative discussion down the road if they are not getting the results they want. We have become very comfortable with using isotretinoin but must remember that for a patient, parent or teen, to consider taking a medication that is teratogenic and needs monitoring may just be too scary to consider, even if it is the only thing that will help.
Often times our failure to navigate it and guide patients through it prevents patients from getting their medication. Prescribers should not delegate iPLEDGE responsibilities to medical assistants without first mastering the system ourselves.
For me this required several months of clearing people and making multiple calls to iPLEDGE, but it was a worthwhile investment. Going through this process, I concluded that it is unrealistic to expect a person with a medical assistant level education to master iPLEDGE on their own. We have to register them and clear them every month but they do absolutely nothing. Whether these patients had blood tests is not a criteria for clearing them. They have a day window to pick up their medication. Registration cannot take place without a pregnancy test and even if the pregnancy test date precedes the registration date, the day window starts on the registration date.
This is why it is important to register patients the day the pregnancy test results come in to avoid delays. Schedule a four and a half to five week follow-up rather than four weeks follow-up for the second visit.
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