Isotretinoin is a retinoid. It's a Vitamin A that has been used since 1982. It's an amazingly effective drug but a very controvertial drug. It's had a very turbulent history but I can't imagine practicing dermatology without Accutane. It's approved to people with severe nodular-cystic acne, or for those who have much milder acne but it's very impactful on their lives. I think that the trend has been to use it earlier rather than later as a high percentage of people - patients and teens will have scarring. The sooner we turn off the acne, the better. Now, the controversial aspects of this drug ar umber one it's teratogenic--Girls can't get pregnant on it because it causes all these horrible fetal abnormalities, but it's out of the system very quickly. A month after you're off the drug, you can get pregnant quite safely. The issue about contraception and avoiding pregnancy, is a huge and obviously very important issue. Other things that have caused controversy is depression and Accutane. There have been a number of studies recently from Sweden and Italy suggesting that there may not actually be a very strong link at all with depression and Accutane. My own suspicion is that it's idiosyncratic. I think that for a very small number of individuals-it may be a brain irritant- they get very black, very down on it, but that recovers, reverses almost as soon as you bring them off the drug. This question about depression and suicide--I think we just have to be observant and make people aware--if there's any truth to it at all, that it's a rare idiosyncratic event probably. Most recently we've had this issue of class action lawsuits in the United States about Accutane and inflammatory bowel disease. There is different viewpoints on this. Most of the studies show no connection between Accutane and inflammatory bowel disease. Another study that shows that with ulcerative colitis, there may be a slight increase in the risk of inflammatory bowel disease with Accutane. Most of the studies will show that the instance of inflammatory bowel disease in Accutane users is not very different from non-users. I think that the reality is that the risk is very small. If you have cramping, bloody diahhrea, clearly you just stop the medication. It has revolutionized the treatment of acne. There are few drugs that cure anything, but Accutane this is one of them. There's nothing more pleasing than to see the teenager with significant acne see you at the start of Accutane--their heads are down they are uncommunicative, and with time they sit up straighter and they look you in the eye--it has a life changing effect. So it's a powerful drug that has to be dealt with caution. You have to monitor it very closely, you have to follow the blood work on it. We mainly check for the fats, the lipids. Rarely does it ever irritate the liver, but we have to monitor that. It's an extraordinary drug.