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He received a cumulative dose of approximately 14,850 mg after 15 months of therapy. Thereafter, his dose of isotretinoin was tapered to 10 mg three times weekly for two months. At this dose, he noted an exacerbation of his skin lesions with darkening of his neck and axillae, with increased thickening of skin here and on his palms (Fig 3). His dose of isotretinoin was increased to 10 mg daily for five months, followed by 10 mg alternating with 20 mg daily. He has now been maintained at this dosage for the past 33 months (cumulative dose 31,500 mg). As his improvement stalled, additional medications were considered. Since he had Bank Accounts For Limited Companies Uk demonstrated slight hyperglycemia on several occasions (serum glucose 102-130) despite normal fasting insulin levels (5 U/ml, reference range 3-25 U/ml) and normal glucose tolerance testing, he was started on metformin (500 mg BID increasing to 1000 mg BID) three months into maintenance isotretinoin starting Additional benefit was observed on combination isotretinoin and metformin therapy, with further improvement of hyperpigmentation in particular (Fig 4).
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