|Best used: PM||Caution: Sensitive or even normal skin||Best for: Anti-Aging, acne, pigmentation, enlarged pores, wrinkles|
|Comments: Most studied ingredient in dermatology||Mode of action: Collagen builder, anti-acne, anti-pigment||Science Score:|
What is the science behind tretinoin?
Tretinoin also known as Retin A or Retrieve belongs to the retinoid family of molecules. These are one of the most important & powerful ingredients in the science of skin care. Tretinoin can reduce oil production, increase the turnover rate of skin cells & stimulate collagen, elastin, as well as the formation of new blood vessels. Tretinoin can also decrease the amount of sun damaged cells, hence its use in anti-aging medicine.
How quickly does tretinoin work?
You may notice tretinoin starting to work within 2 to 3 weeks, but it can take 6 weeks or more to experience the full benefit. This is in the context of acne, just don’t expect tretinoin to erase your wrinkles. Retinol & retinoids are best used in the context of prevention, rather than reversal. A true ‘wrinkle removal cream’ is a unicorn .
What skin conditions can be treated with tretinoin?
Retinoids can be used in over 150 skin conditions including-
- Treatment & prevention of acne, blackheads, whiteheads
- Anti-ageing medicine to reduce wrinkles, fine lines & sun damage
- As a pigment corrector to treat melasma & hyperpigmentation
- As a superficial chemical peel
- Pore regulation & treatment for enlarged pores
- Reduction of excessive oil production
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Which is stronger tretinoin or retinol?
Tretinoin is stronger than retinol. The latter requires conversion to retinoic acid before it can exert its molecular might. The flipside is that tretinoin has a much much higher incidence of skin irritation, or ‘retinoid dermatitis’. Almost everyone will experience irritation with tretinoin; it really depends on the concentration, frequency of use as well as innate skin sensitivity.
Should you use tretinoin every night?
The question should be, can you tolerate tretinoin every night? If you can tolerate the nightly application of tretinoin, go for it. The majority of people will have this topical as part of their skin care routine which may include other activities such as ascorbic acid, AHAs, BHAs, combination acids & antioxidants. These topicals may decrease your skin’s threshold for irritation, hence most people will have some form of irritation with medical grade prescription retinoids. See application guide to understand how to incorporate tretinoin into your skin care routine.
How can I incorporate tretinoin in my anti-aging skin care routine?
Tretinoin is best used as part of a combination skin care routine. My suggestion is that all patients start with a good formulation of retinol prior to tretinoin as the latter can result in skin irritation. Once you have mastered retinol, you can cautiously add tretinoin into your skin care overhaul.
Start every second night, rubbing a small pea size amount of tretinoin onto your forehead, cheeks, chin and other areas in which you notice wrinkles. Avoid applying tretinoin directly to your lips, sides of your nose & areas close to your lips, as these parts of the face can potentially become irritated. Tretinoin is best combined with other topical creams including antioxidants, niacinamide & targeted skin care products. Be guided by your skin care specialist.
Can I use tretinoin if I have sensitive skin?
Yes, however it is much easier titrating retinol into your skin care routine compared to the more powerful version of vitamin A, namely tretinoin. Once you have mastered retinol, you can cautiously titrate tretinoin into your skin care routine as tolerated. Sensitive skin patients including rosacea patients can start as follows-
- Combine half or even quarter pea size amount of tretinoin with your moisturiser
- Apply test spot to front of ear
- If no reaction, proceed to apply once a week to target areas
- If you have reactive skin, decrease use
- Titrate as clinically tolerated
- Be guided by your medical dermatologist (refer to disclaimer below)
Patients with sensitive skin should ideally be treated with laser & light-based technology, topicals including chemical peels should be avoided.
Disclaimer: If you have sensitive skin and would like to pursue topical treatments as part of your skin care routine, please consult a medical dermatologist & not myself. In some cases, testing is required to exclude contact dermatitis. This is a medical investigation as some cases may require allergic patch testing. This is beyond my speciality interest.
Can tretinoin be used on rosacea patients?
Technically yes, but titration is required. Discuss this with your dermatologist. A much better solution is retinol, as it has less irritation. If you suffer rosacea, the first skin care active should be vitamin B, namely niacinamide as this is anti-inflammatory.
For anti-aging, rosacea patients will benefit from laser & light-based modalities over topical & chemical peels.
Can tretinoin be used to treat blackheads & acne?
Yes, topical retinoids are one of the most effective treatments for blackheads, whiteheads, zits, pustules & cysts. Here are some facts regarding tretinoin use for the management of acne:
- Apply tretinoin to acne prone areas & not spots
- Retinoids are best at preventing not treating acne lesions
- It may take 6-8 weeks for maximal effect
- Irritation can occur as acne is often associated with a compromised skin barrier function
- Start slowly, namely every second night
- Moisturise if you experience dryness
- Purging is commonly seen with retinoids, this lasts 2-3 weeks
How can tretinoin help enlarged pores?
A double-blind study found that tretinoin & retinol can reduce the appearance of large pores. This form of topical vitamin A can reduce oil production by overactive pores, additionally production of collagen, elastin and hyaluronic acid provides the support for large pores.
Pore reduction is best achieved with combination therapy including the use of retinol/retinoids, AHA or BHA compounds, & in most cases conservative laser resurfacing or clinical strength chemical peels.
Can hormonal acne be treated with tretinoin?
Retinoids can help treat hormonal imbalances by modulating the oil gland. Tretinoin does not affect the hormonal imbalances that can lead to adult hormonal acne. Tretinoin can reduce oil production & normalise abnormal shedding of cells that may lead to outbreaks. Ideally hormonal acne should be treated with lifestyle modification, correct use of products, topicals including tretinoin, & in severe cases medications to keep your hormonal balance in check. Be guided by your medical dermatologist.
*Disclaimer: I am a procedural dermatologist, I do not treat medical cases including hormonal acne. For these cases, consult my colleagues @cutis_dermatology
Can tretinoin reverse wrinkles?
Tretinoin belongs to the family of retinoids—the most used and most studied anti-aging compounds may reduce fine lines & wrinkles. Used correctly, tretinoin is more effective in preventing wrinkles, rather than treating them. Simple procedures including clinical chemical peels, fractional lasers, Tixel, microneedling & Botox produce far better & more predictable results than any anti-wrinkle cream.
Should I moisturise before or after tretinoin?
Several options. If you have normal skin, you can apply moisturizer with tretinoin, bearing in mind that you may dilute it, depending on the amount of each you use. Another method is called the sandwich technique. Apply a base layer of your favourite moisturizer, then apply tretinoin. Studies have shown that the base layer does not dilute or reduce the efficacy of the retinoid, in fact it helps with tolerability. Look for ingredients such as glycerin, hyaluronic acid or squalene as a key moisturizing ingredient. The final step in this sandwich technique is another coat or moisturizer. So it goes something like- moisturise, tretinoin (or other retinoid), moisturizer.
Word of advice; if you have any side effects associated with retinoid therapy, apply a bland moisturiser frequently. This can mean up to and even beyond three times a day.
Can tretinoin be combined with ascorbic acid?
Yes, but not at the same time. When used in the right order, Vitamin C should be applied in the morning as it protects your skin from UV induced collagen loss, whilst
tretinoin at night as this builds new collagen. The most important concept to understand is that everyone has a different skin threshold namely your skin type may not tolerate this combination. If you have any irritation, redness, burning or flaking, stop your ascorbic acid for five days, then recommence as TOLERATED.
Which skin products are compatible with tretinoin?
Hyaluronic acid is the standout topical compatible with virtually everything, followed by niacinamide. Some prescription formulations combine retinoids with other ingredients such as hydroquinone. Be guided by your skin care expert.
Skin ingredients interactions are extremely complex with no hard and fast rules as the biggest unknown factor is YOUR skin’s threshold. Exert common sense when combining ingredients, namely- start slowly, apply a test patch area, & above all listen to your skin. If you have any irritation, back off, & let your skin recover.
What products should NOT be mixed with tretinoin?
Unless your skin care specialist tells you otherwise, it is especially important to avoid using the following skin products on the same area as tretinoin: benzoyl peroxide, salicylic acid, *lactic acid, *glycolic acids, *citric acid, high strength ascorbic acid. These acids & actives will increase skin irritation.
*For advanced & sensible skin care junkies, tretinoin can be combined with acids. The latter acts as a priming agent to enhance the penetration of retinoids. Ascorbic acid should ideally be used in the am, retinoids in the pm. Be guided by your skin care expert.
Can I use tretinoin on my neck?
Yes. Start off with a pea size amount of actives, mix with your moisturizer of choice, apply alternate nights and increase as tolerated. If you peel, itch, go flaky, go red, or if you have stingy skin, you have exceeded your skin’s threshold. Stop for 5 days, then restart slowly. Application should be at night.
Will my skin purge with tretinoin?
The ‘retinoid purge’ period is common if you suffer from acne or blackheads. This is because retinoids increase the turnover of skin cells. This normally lasts 7-21 days. Alternatively, during the Tretinoin Purge, your skin might feel too dehydrated, and start over-producing oil. This is also very common and completely normal.
How does tretinoin compare with adapalene & Zorac - tazarotene?
These molecules are all members of the retinoid family. Tretinoin is generation one, adapalene or Differin is generation two, whilst tazarotene or Zorac is generation three.
|Most powerful||Zorac + Aklief|
|Most Frequently used|
What strength tretinoin is best for wrinkles?
The answer is not the strength, & the question would strength retinol or retinoids can YOUR skin tolerate? Tretinoin usually comes in 3 strengths – 0.025%, 0.05%, and 0.1%. Compounded topicals go up to 7 percent tretinoin. This is reserved for clinical peels under supervision.
0.05% is seen most often for anti-aging preparations to reduce the appearance of fine lines, however most patients cannot tolerate nightly application of this strength. I suggest starting off with good retinol, pushing up to the highest OTC concentration before embarking on your RETINOIC ACID journey.
At what age should I start retinol?
Starting in your mid 20s would be sensible. Having said that, it is never too late to start caring for your skin! In fact, the oldest patient I started on retinoids (topically) was in her 90s!
What are the side effects of tretinoin cream?
Unless you have retinoid receptor resistance (one in a million), EVERYONE who applies topical prescription retinoids WILL have side effects. This threshold depends on the concentration of tretinoin, application frequency, skin barrier function & your innate skin sensitivity.
Side effects include:
- Burning, itching, stinging, scaling, or redness of the skin.
- Chapping or slight peeling of the skin (mild to moderate)
- Darkening of the skin.
- Lightening of normal skin colour.
- Lightening of treated areas of dark skin.
- Purging of acne
- Redness of skin (mild)
- Unusual dryness of skin (mild)
- Unusually warm skin (mild)
Why is tretinoin prescription only?
Because of Retin A’s power in bringing about changes, it only makes sense that there’s an increased potential for side effects. This is the primary reason why the FDA & TGA classified Retin A / Retrieve / Tretinoin as a prescription medication.
I do agree with this view as I feel that the absolutely majority of consumers will run into trouble with powerful retinoids. Having said this, retinoid use is not complicated providing you follow some simple steps, as illustrated in this write up.
A contradiction is that Adapalene or Differin, which is a more powerful second-generation topical retinoid is available over the counter in the United States & in some European countries. (Though Diffein has a more powerful action against acne compared to tretinoin, the side effect profile is marginally less). This is due to Galderma’s strategic marketing & funded drug trials, smart financial move by this pharmaceutical company.
Regulation is also required due the pregnancy rating of retinoids, namely Category X. The logic does not hold for adapalene. You can obtain a prescription for topical retinoids including tretinoin/Retrieve or Differin/adapalene from your local general practitioner or nurse practitioner.
Are there non-prescription alternatives to Tretinoin?
If you like the idea of the results tretinoin produces, but aren’t keen on the associated side effects, there are other options available. Non-prescription retinol products have been shown to be effective, without the side effects. Keep in mind that the results may take a little longer to achieve & that the quality, especially the formulation of the product is the key. Look beyond the concentration of retinol.
A sensible step is to start at 0.5% retinol every second night, thereafter, increasing the frequency of application. If you tolerate this for 3 months, increase your application concentration to 1%, again starting every second night.
Can tretinoin be used in pregnancy?
No. Retinoids including tretinoin, retinoic acid & even retinol cannot be used in pregnancy. This is because high doses can lead to foetal birth defects. If you find out you are pregnant on a topical retinoid, cease immediately. The chances of a topical retinoid causing birth defects is extremely unlikely- most experts say zero, however you should discuss this with your obstetrician.
How can I get a prescription for tretinoin?
Please consult your doctor or dermatologist to see if tretinoin is suitable for your skin condition. This extensive write up of tretinoin is designed so that patients can try this topical prior to seeing a dermatologist. Your GP can provide you a prescription for retinoids.
*Disclaimer: I am a procedural dermatologist, namely my work involves surgery, laser, & injectables. Skin care is common knowledge possessed by all dermatologists. For skin care advice, discuss with your medical dermatologist, alternative consult with my clinical team of dermal therapists & nurses @cutis_dermatology
How do I incorporate tretinoin in my daily skin care routine?
A sensible skin care routine that involving tretinoin goes something like this;
AM: Lactic acid wash, SPF, Make up, with the option of antioxidants (Ferulic acid, Ascorbic Acid, Tocopherol)
PM: Cleanser, actives such as Niacinamide, Hyaluronic Acid, Tretinoin or Retinol
*There are many formulations of retinoids with endless combinations. The use of other acids such as ascorbic, retinoic, azelaic etc… are not absolutely contraindicated. A sensible starting point is to use Tretinoin every other night and gradually incorporate it into your routine. If in doubt, dilute the active with a moisturiser, & conduct a test patch. Be guided by your skin care expert.
Davin’s Skin Protip
Prescription retinoids are by far the hardest skin care active to get right. The reason is that patients are way too ambitious with the amount applied, frequency of application, eagerness to combine this with other activities & their overall expectations. The biggest mistake is using too often. Always titrate the dose, start once a week, increase slowly as tolerated. Listen to what your skin is telling you. If you have sensitive skin & you can’t use retinoids, don’t force it or you will go backwards. Topical tretinoin is NOT a wrinkle eraser. It is not a miracle anti-aging cream, it is not designed to get rid of fine lines, nor pigmentation, it cannot cure melasma, & it will not boost your collagen levels, so your cheeks are fuller & you don’t have any more nasolabial lines. These changes can be demonstrated in the laboratory, & or with macro clinical photography. Having said this, tretinoin is a superpower topical that can be incorporated into your ‘preventive regimen’, & ideally should be combined with sun protection & antioxidants.
Advice for people who want to start on tretinoin, don’t. Master topical retinol first, then graduate to the use of retinoids. It’s like a class, beginners use OTC retinol, intermediates go to low strength retinoic acid– prescription retinoids. Advanced users can even ‘prime’ their skin a few days prior to higher strength retinoids as it increases penetration & clinical efficacy.
Disclaimer: My work is a procedural dermatologist, the concepts authored on this page, along with other pages are widely known by all dermatologists, & skin care experts throughout the World. Be guided by yours. I do not routinely commence patients on retinoids a part of a skin consult, as I only consult for procedural work. Having said that I do provide my patients with a comprehensive prevention guide after any surgical, laser & or injectable procedures. For skin care advice, please consult my clinical team @cutis_dermatology. An in-depth skin care consultation can take up to 25 minutes, especially in complex cases.
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