Topical Tretinoin – How Does It Work? What to Expect?
Dear readers,
Today I wanted to look into Topical Tretinoin use. Topical retinoids have been around for awhile now and I wanted to explore what is their efficacy according to the literature available and what to expect from their use on aging skin.
For decades topical retinoids have been one of the well known treatment options for aging skin. Tretinoin 0.1% cream has shown impressive results in skin appearance after 8 to 12 months of treatment. The side effects reported after use were mild burning sensation in the eyes and tretinoin dermatitis.
The terms ‘intrinsic’ and ‘extrinsic ageing’ (photoaging) describe two different aspects of the ageing process that occur in the skin.
Intrinsic aging of the skin is characterised by thinning, loss of elasticity and deepening of normal expression lines.
Photoaging refers to those skin changes induced by chronic exposure to the sun.
Extrinsic aging is characterised by wrinkled, yellow, lax, rough, leathery, telangiectatic and spotty hyperpigmented or hypopigmented skin.
Sun is not the only environmental factor causing changes superimposed on intrinsic ageing. Smoking cigarettes can cause prematurely aged skin appearance. Long-term exposure to other environmental factors such as wind, heat and chemical toxins might also contribute to an aged appearance.
The response of photoaging to topical tretinoin appears to be dose dependent.
Stronger concentrations and more frequent application (up to twice per day) has shown to lead to better results. It would appear logical that lower concentrations of topical tretinoin need to be used for longer periods than the higher concentrations to have improvement in skin appearance. However, regardless of the concentration, the greatest response to topical tretinoin therapy was observed during the initial 6 to 9 months,.
Starting with the highest concentration cream commercially available, tretinoin 0.1% cream, on a daily basis is beneficial.
The treatment of ageing skin has classically relied on the use of cosmetics, physical modalities like phenol and acid peels, injections of collagen or autologous lipid and surgical techniques like blepharoplasty and face lifts. Although capable of successfully altering the clinical appearance of aged skin, these procedures are costly and make no attempt to treat the underlying causing factors.
Successful medical treatment of photodamaged and aged skin is possible with topical tretinoin.
Application of 0.05% tretinoin cream for 3 to 12 months led to marked improvement of the facial skin. There was evidence of new collagen formation in the superficial dermis, new vessel formation and exfoliation of retained follicular horn. Tretinoin-treated skin showed increased blood flow, increased trans-epidermal water loss, and greater permeability to dimethylsulfoxide.
Topical tretinoin can partially reverse the structural damage associated with photoaging, and it may be useful in slowing down the photoaging process.
Evening application of topical tretinoin is advisable in the initial phase. All-trans-retinoic acid can be deactivated from sun exposure, rendering it less active; bedtime applications help to minimize this effect. Evening applications increase patient compliance as patients are more likely to remember to apply the medication as part of their bedtime routine. Many patient have reported that tretinoin cream was greasy, so bedtime applications are more acceptable. As a result of the greasiness, women have noted that it was difficult to apply cosmetics in the morning immediately after the use of tretinoin cream. Thus it might be preferable to use tretinoin solution (0.05%) or gel (0.025%), along with moisturising cosmetics, in patients using daytime application of tretinoin.
Once there is tolerance to daily tretinoin applications, we advance them to twice-a-day applications. Rarely, someone cannot tolerate tretinoin 0.1% cream, so application of 0.05% cream is acceptable. People with aged skin tend to have dry skin, so it is preferable to use cream base, when possible, for its mild emollient effect.
Beneficial effects of tretinoin therapy can be seen as early as 2 weeks after the start of therapy.
In the beginning patients can experience a subjective tightening of the skin and a pink, rosy glow. Evident improvement in wrinkling were often seen after 2 to 4 months of starting therapy.
The longer patients used topical tretinoin, the greater was their improvement in photoaging.
In most patients impressive improvement was noted between 8 and 12 months of therapy. Application of tretinoin 3 to 4 times per week afterwards, has been sufficient to maintain the improvement attained over the initial year of therapy.
Thinning of the skin, visible tiny blood vessels and mottled patches of light and dark pigmentation on the sides of the neck have not responded to tretinoin therapy as much as have other parameters of extrinsic ageing (wrinkling and skin texture). The reasons for this lack of response are not entirely obvious. One would have expected the mottled hyperpigmentation to decrease since the pigmentation associated with lentigines fades partially or totally with tretinoin therapy. However, failure of the other components such as hypopigmentation, telangiectasia and atrophy to improve may have overshadowed any improvement in the hyperpigmentation, rendering such changes undetected.
Most people using topical tretinoin are happy with its effects and exaggerate the virtues of the medication. Patients often tell us that their friends have noted substantial changes in their appearance.
Most objective improvements with tretinoin therapy are more subtle than those described by patients.
To find the right patients for this type of ageing skin program also plays an important role in the success of the program. Dedicated patients make an effort to understand the role of sun exposure in photoaging and that sun avoidance is desirable. They are encouraged to use sunscreen for sun exposure during normal daily and recreational activities.
People who see sunbathing as part of their lifestyle are not encouraged to use topical tretinoin for photoaged skin, regardless of their willingness to use sunscreens.
They don’t understand the basic principles behind an ageing skin program and are not likely to benefit from the use of topical tretinoin.
Perhaps the most important advantage of topical tretinoin therapy for extrinsic ageing is that it promotes early detection of skin cancer.
It is essential when assessing patients on ageing skin clinic to screen them for actinic keratoses, basal cell carcinoma, squamous cell carcinoma and melanomas. Patients spend more time caring for their extrinsic ageing, and thus begin to note new lesions as they arise, requesting treatment for actinic keratoses and various nevocellular lesions.
Topical retinoids have effects on intrinsic ageing similar to those of extrinsic ageing.
Retinoid dermatitis has been a problem during treatment of aging skin with all-trans-retinoic acid agents, but this side effect can be mitigated by the use of topical steroids and emollients and by temporarily lowering the frequency of applications. Patients’ tolerance to dermatitis is better if they are informed in advance of its likely occurrence. If patients cannot tolerate it, the frequency of application is decreased to every other day or even every third day initially. As patients’ skin accommodates to the retinoid dermatitis, daily applications can be encouraged again.
Patients with type I skin type are most likely to develop the retinoid dermatitis. Different parts of the body show a variability in their susceptibility to this irritation.
The most susceptible areas to dermatitis are the sides of the neck, the V-area of the neck and chest, the ventral arms and the antecubital fossae.
The face, dorsum of the hands, the dorsal arms seem to tolerate topical tretinoin well. Different areas of the body can be treated with the same concentration of topical tretinoin but with varying frequencies. For example, a patient can apply tretinoin 0.1% cream daily to the face, every other day to the neck and twice a day to the arms. Patients naturally learn how to use different concentrations in order to control the retinoid dermatitis. Most patients can be treated with only one concentration of topical tretinoin. During the course of therapy, a small patch of dermatitis can develop in a patient who is otherwise tolerating the tretinoin therapy well (a small patch on the chin or the forearm). In such cases the use of mild to moderately potent topical steroids (triamcinolone) can help to reduce the inflammation and allow therapy to continue.
Factors that appeared to trigger and worsen the tretinoin-induced dermatitis were sweating or heat immediately after application of the medication, prolonged exposure to sunlight, and occlusion of the medication by watches or other jewelry. There were varying degree of erythema, namely, pinkness and inflammation of presumed subclinical actinic keratoses. The three reactions are distinguished as follows.
Tretinoin-induced dermatitis. This is a side effects of tretinoin therapy. It is characterised by dryness, peeling and subjective irritation occurring within the first to tenth week of topical tretinoin therapy with predilection for intertriginous sites.
Pinkness. This should be viewed as a benefit to tretinoin therapy. Both clinicians and patients viewed this pinkness as a desired effect of treatment. Pinkness is not generally associated with dryness, peeling, or subjective symptoms of irritation and tends to start after 1 week to 2 months of tretinoin therapy. This reaction consists of a light erythema on the tretinoin-treated areas. Pinkness develops both treated and non treated skin.
Inflammation of presumed subclinical actinic keratoses. This is a desired effect of therapy, since it may cause disappearance of these lesions. It tends to occur after 3 or more months of topical tretinoin therapy. The inflammation may be punctate or reticulate and is accompanied by dryness and scaling. This reaction may be difficult to distinguish from tretinoin-induced dermatitis except for its usually later onset and discrete pattern. This inflammation may be superimposed on the pinkness. Resolution of this inflammation occurs with continued treatment while the pinkness remains.
Many patients have tolerability issues when initiating use of retinoid-containing products, often experiencing redness, dryness and peeling, thus deterring their use. It is important to develop an effective barrier adjunct to build skin tolerance to a prescription-strength retinoid cream. MPF is a cosmetically active ingredient that provides significant reduction in transepidermal water loss (TEWL) relative to its vehicle (cream, gel-matrix, solution). For patients experiencing retinoid irritation, use of a cream in combination with the retinoid treatment was shown to reduce issues of dryness and peeling significantly. There was also a significant reduction in barrier disruption (TEWL) associated with the use of the retinoid treatment alone.
Additional use of moisturisers is often recommended for facilitating facial retinoid application. Lightweight gel-matrix and cream moisturisers have clinically shown to provide immediate and long-lasting skin hydration and barrier improvements. They are well tolerated in patients with atopic dermatitis, rosacea, acne vulgaris, and sensitive skin.
There are different treatment protocols like: use of retinoid formula alone, a 2-step regimen of retinoid + moisturiser or moisturiser + retinoid (open sandwich), or a 3-step regimen of moisturiser + retinoid + moisturiser (full sandwich). Full sandwich regimen demonstrated reduced retinoid bioactivity, indicating lower penetration. “Open sandwich” in either order of application maintained comparable bioactivity to the retinoid treatment alone, demonstrating compatibility of the regimen. “Full sandwich” is recommended for new retinoid users who may experience sensitivity during the skin acclimatisation period. The gel-matrix or cream moisturiser can be used long-term in the “open sandwich” regimen with topical retinoids to provide barrier benefits without impacting retinoid bioactivity.
One of the reported side effects of tretinoin 0.1% cream was a transient, mild burning sensation in the eyes. The burning was not from the medication actually entering the eye, but apparently is caused by transient evaporation of an unknown irritating volatile material from the cream. This occurs when the cream is applied around the eyes or close to the lid margins and lasts about 30 seconds. Patients need to be informed in advance that this burning is to be expected and is not to be confused with entrance of the medication into their eyes.
The clinical improvements in photoaging of facial skin have been confirmed. Most improvement was noted in fine wrinkling, coarse wrinkling, pinkness, roughness and hyperpigmentation after 8 to 12 months of treatment. The only drawback was the tretinoin-induced dermatitis, which was generally well-tolerated. Topical tretinoin can be used as adjunct to the well known rejuvenating surgical procedures in the treatment of the ageing face.
Thank you for reading, dear friends. I found this information very useful and it certainly answers a lot of questions. I would like to emphasize that topical tretinoin can be used for aging skin. In the recent years there has been a tendency for younger people even teenagers to start using these topical agents in the pursuit for “ideal” skin appearance. This can have a significant damaging effect on the young skin. My advise would be to consult a dermatologist if such treatment would be beneficial or if it is even needed.
Till next time.
Best wishes,
Venelina
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