Oral isotretinoin is a highly effective drug for severe acne but with ongoing serious safety concerns and we are cautiously reminded by the Medicines and Healthcare products Regulatory Authority to prescribe this drug within licence. We review the National Institute for Health and Care Excellence recommendations for considering referral of acne to specialist care and propose some improvements. This may help manage patient expectations of treatment, ensure only appropriate patients are seen in secondary care and help prescribers remain within the isotretinoin product licence.