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Tretinoin | What is tretinoin and how do I use it?

Updated: Feb 9, 2023

Tretinoin is available as a prescription topical to treat a number of skin conditions. Read more...

 

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Video: Techei

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What is Tretinoin?


There is a fairly good chance that if you have visited a Dermatologist in the past 40 years for acne tretinoin may have been discussed and/or prescribed during your visit. Tretinoin is a retinoid, a vitamin A derivative. It is also known as all-trans retinoic acid. Since we cannot synthesize our own vitamin A, we must obtain Vitamin A from our diet and/or topical formulations. Back in World War I, vitamin A deficiency was noted to be associated with skin-related changes such as dry skin and rough hair bumps. By the 1960s through 1980s, topical formulations were found to have many uses in dermatology.


Is tretinoin a prescription?


Tretinoin is available as a prescription topical to treat a number of skin conditions.


Tretinoin topically has FDA approval for the treatment of


  • Acne (Tretinoin for acne regulates oil or sebum production, assists in the exfoliation of the skin, and accelerates the improvement of pigmentation from acne evening the skin tone.)

  • Photodamage (tretinoin for wrinkles, fine lines, lentigines, etc.)


There is a version of tretinoin that is systemically used to treat acute promyelocytic leukemia (APL).



Tretinoin cream uses considered off-label your Dermatologist may prescribe tretinoin for including:

  • Keratosis Pilaris

  • Stretch marks (Striae distensae)

  • Flat Warts

  • Necrobiosis Lipoidica (diabeticorum)

  • Nail Psoriasis

  • Psoriasis

  • Acanthosis Nigricans

  • Ichthyosis

  • Darier’s Disease (Keratosis Follicularis)

  • Porokeratosis

  • Melasma

  • Actinic keratoses (In conjunction with field cancerization therapy)


 


 

How is tretinoin prescribed?



Tretinoin is a topical available as tretinoin cream and tretinoin gel forms. It comes in strengths of 0.01%, 0.025%, 0.05%, 0.1%. There are some strengths available between these numbers, however, these will often be name-brand formulations of tretinoin.


The form and percentage prescribed by your Dermatologist are often determined by your skin type, condition to treat, and tolerance. Since tretinoin can be drying when used, it is best to rely on the experience of your Dermatologist to determine the best formulation to use. Tretinoin was patented back in 1957 and became available for medical use in the 1960s.


Generic forms are widely available these days and made primarily by Padagis and Taro Pharmaceuticals.


Some of the common brand formulations of tretinoin include:

  • Atralin

  • Avita

  • Refissa

  • Renova

  • Retin-A & Retin-A Micro

  • Tretin-X


How do I use tretinoin?


Tretinoin can cause dryness and irritation as it begins to work. There are several ways to approach using tretinoin to balance the benefits with the side effects.


Step 1: Apply at night. Sunlight can potentially deactivate or degrade tretinoin making it less effective if applied during the day. For best results, apply at night before bedtime. It is considered safe to use tretinoin in the summer time remember that wearing an SPF-containing sunscreen is essential in the morning. Due to some exfoliation with the use of tretinoin, the use of sunscreen will help protect your skin more effectively from UV exposure.


Step 2: Apply to the entire face when treating acne or actinic damage. Remember that tretinoin is actively treating AND preventing. Squeeze a pea-sized amount into the palm of your hand, then use the dip-dot-smear method to evenly distribute across your skin.


Step 3: Apply an SPF-containing moisturizer every morning. There is also a photo or sun sensitivity that can occur. Wearing sunblock every morning while limiting tretinoin to nighttime use is helpful. If you are just starting with tretinoin, consider applying every other night or every third night for the first couple of weeks to build up a tolerance before applying nightly.



If your skin is sensitive or dry, it is reasonable to apply a moisturizer after or even before applying the tretinoin to reduce irritation. Any moisturizer is reasonable to consider avoiding ones that contain acne or antiaging ingredients. Try to choose a moisturizer that contains ceramides for added hydration.

If you are experiencing:

  • Dryness

  • Irritation,

  • Excess exfoliation

  • Skin sensitivity

  • Burning sensation

Then, discontinue the use of tretinoin for a few days to a week while continuing your moisturizer to combat dryness. If side effects are experienced from the use of tretinoin cream, stopping abruptly is absolutely reasonable and recommended. Once the product is discontinued, depending on the severity of the symptoms, it can take upwards of a week to resolve completely. Use of a mild hydrocortisone 0.5% cream twice daily for 2-3 days can help reduce irritation as well. Discuss with your Dermatologist before resuming therapy. It is best to resume use in consultation with your doctor for the best results.


 



 


Can anyone use tretinoin?


Technically any age group may be prescribed tretinoin although it may make sense to alter the frequency of use and tailor the treatment regimen based on what is being treated. Tretinoin is well known to treat acne and work as an anti-aging product. In some cases, it may be recommended for every other day or twice weekly use to gain the benefit and reduce the side effects.


 

 



Is there anyone that should NOT use tretinoin?



Tretinoin is a prescription product in the United States. To obtain a prescription it is important to be seen and evaluated by your Dermatologist to see if it is right for you and to review its use. It is considered pregnancy category C which means that discussion with your Dermatologist is important if you are planning/not preventing pregnancy or nursing.



 



 


What is a Retinoid?

Retinoids work by acting on receptors in our cells called retinoic acid receptors (RARs) that work with retinoid X receptors (RXRs) to exert an effect on the cell. The effects can range from an increase in cell turnover that can lead to chemical exfoliation of the skin, fade discoloration, contribute to softening or smoothing of the skin, and increase collagen production to improve the appearance of fine lines and wrinkles. Tretinoin can also play a role in the chemoprevention of skin cancer by modulating DNA repair.

Is tretinoin a retinol?



Tretinoin and retinol are both considered first-generation retinoids, however, they are different in terms of their structure and effectiveness. When it comes to tretinoin vs retinol, retinol is converted into retinoic acid by the skin after it is applied.


Is tretinoin the only retinoid?



Retinoids are classified as generations. Retinoid generations represent the development process over the years with each generation taking on specific physiochemical properties that make them bind more specifically to certain receptors, improve tolerance and reduce side effects.





​Name

​Generation

Oral or topical

Use

Retinol

First

Topical OTC

Anti-aging

Retinaldehyde (labeled on products as Retinal)

First

Topical OTC

Anti-aging

Tretinoin

First

Topical


Oral


​Rx: Acne, anti-aging Rx: Acute promyelocytic leukemia

Isotretinoin

​First

Oral

​Rx: Acne

Alitretinoin

​First

​Topical





Oral

​Rx; sores associated with Kaposi’s Sarcoma



Rx not available in the US; hand eczema

Etretinate​

Second

Oral

​Rx: Psoriasis

Acitretin

Second

Oral

​Rx: Psoriasis

Adapalene

Third

Topical

​OTC: Acne

Tazarotene

Third

Topical

Rx: Acne, psoriasis

Bexarotene

Third

Topical

​Rx: Cutaneous T cell lymphoma



Since Adapalene is over the counter when it comes to adapalene vs tretinoin, is there one that is better than the other?


Adapalene is thought to be better tolerated but perhaps less effective compared to tretinoin or tazarotene. It is also more stable in sunlight making it possible to use during the daylight hours for those that may not be able to keep up with a nighttime skincare routine.



I think it is reasonable to start with adapalene given that it is over the counter to see if you gain any benefit from use. If you still struggle with your breakouts, then it is time to see your Dermatologist for re-evaluating your skin, and your routine, and give consideration to prescription options.


Do I ever have to stop using tretinoin?



I got my first prescription for tretinoin when I was 16 years old and have not stopped using it for 30 years (except during each of my pregnancies). My first prescription was for acne, however, I found that the texture of my skin improved as did my complexion so I continued to use it.




What if tretinoin clears my acne, then it comes back after I use it- did it not work after all?



Try to avoid abrupt starts and stops with tretinoin. I often see patients use the topical in “spurts” - use it routinely for a few nights, dry out too much, then stop altogether, then delay restarting until acne flares for example and restart. By finding a routine - every day, every other day, every third day, etc- tretinoin has a better chance of benefiting the user through both treatment AND prevention.



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