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Isotretinoin is a derivative of vitamin A (13-cis retinoic acid) and represents the first generation of retinoids. It affects all the key factors in the pathogenesis of acne and all current guidelines agree that it is still the most effective therapeutic option in the treatment of acne. In addition to conventional treatment, the modern concept of treatment allows various other protocols, so proper selection of patients and adjustment of isotretinoin treatment modality to the type and severity of acne is necessary to obtain optimal results. Although it was introduced into dermatological practice 40 years ago, this drug is still accompanied by certain controversies and doubts among doctors and patients. The main source of doubt is potential side effects such as teratogenicity, depression, suicide, and inflammatory bowel diseases. Decades of experience have shown that side effects (apart from teratogenicity) are mostly mild, reversible and rare. This paper presents modern approach regarding dosage, monitoring of patients during the treatment, as well as the identification and management of side effects.

Scleredema adultorum (SA) is a rare sclerotic disorder characterized by non-pitting induration of the neck with acral progression, sparing hands and feet. We report on a 57-year-old male with severe SA associated with paraproteinemia, treated with methotrexate. Such widespread skin thickening followed by severe movement restriction and inability to function on daily basis, as in our patient, has never been described. Severe osteoarthritis and finding of HLA-B39 allele in association with SA has not been previously described either. To the best of our knowledge, up to 40 patients with SA associated with paraproteinemia has been reported so far, and currently, there is no established effective treatment protocol. In our patient, low-dose methotrexate resulted in stiffness reduction, increased motility of the trunk and extremities, and ability to function on daily basis. We believe that any information about treatment outcome in SA patients should be disseminated in order to establish consensual treatment protocol for this rare disease.