Current data on complex pathophysiological mechanisms of the relationship between obesity and severe, resistant forms of acne are presented. Special attention has been paid to meaning of insulin resistance and hyperinsulinemia as key elements aggravating the course of acne. Hyperinsulinemia directly stimulates sebum hyperproduction and follicular hyperkeratosis, as well as potentiate hyperandrogenism and systemic inflammation associated with excess visceral adipose tissue. Based on the analysis of recent clinical studies, the feasibility of metformin application as a pathogenetic adjuvant therapy for the correction of metabolic disorders in patients with acne and overweight is substantiated. The benefits of systemic therapy with isotretinoin in the form of Lidose in patients with overweight, associated with improved bioavailability regardless of food intake, are emphasized. An algorithm for managing patients with acne in presence of obesity, including mandatory assessment of metabolic status (calculation of the BMI, HOMA-IR index), interdisciplinary interaction with an endocrinologist and step-by-step therapy prescription: metformin for metabolic background correction followed by the addition of isotretinoin-Lidose, is described. Combined therapy, aimed simultaneously at the elimination of skin manifestations and systemic metabolic dysfunction, is the most effective way to achieve persistent acne remission in this category of patients.