Tretinoin

What is tretinoin?

Mela Cream is a mixture of pigment correctors that come prepackaged in standard concentrations. Think of it as a tube full of pigment inhibitors made by Dermaceutic.

What is it good for?

It is used to improve the appearance of-

• Fine lines, wrinkles
• Sun damage
• Pigmentation
• Acne
• Oily skin
• Enlarged pores

How good is it for pigmentation?

It is a 3 out of 10 for pigmentation, as there are more focused anti-pigment ingredients that work better; azelaic acid, kojic acid, hydroquinone & ascorbic acid to name a few.

Tretinoin is best used as a pigment preventer, especially for mitigating sun spots. It is also used as an agent to maintain the results you get from lasers & chemical peels.

How to use it?

Apply once at night after washing your face. Start slowly, namely every other night. Do not mix with other ingredients (initially).

In the context of pigmentation reduction, retinoids such as tretinoin & retinol are mostly used during your depigmentation phase.

How long does it take before working?

Tretinoin takes 6 weeks before seeing some sort of results (at best). It is best used as a preventer or mitigator, rather than a ‘fixer’, despite all the marketing out there.

Most patients will achieve a 5% to 30% reduction in pigmentation, not enough to make a real difference in conditions like melasma. The same applies to fine lines & wrinkles. Though herald as a miracle cream for anti-aging, the results are not profound. Regardless, retinoids are useful agents to add to your skincare routine.

How to reduce skin irritation from tretinoin?

Slow in and fast out. Start 2-3 nights per week, increase as tolerated. Start with 1 ⁄ 2 pea size amount, dilute it in moisturizer, then reduce the moisturizer bit in the subsequent weeks.

Tips

• Moisturize after application
• Do not exfoliate before
• Be careful of combinations (refer below)
• Buy good formulations

What should not be mixed with tretinoin?

An easy rule to remember is no acids, bar azelaic acid. For advanced users, it goes something like this-

Low irritant potential: Azelaic acid, niacinamide, green tea, vitamin E.

High irritant potential: Glycolic, lactic, & salicylic acid, ascorbic acid (vitamin C), hydroquinone, kojic acid, retinoic acid.

Can I apply tretinoin to my neck?

Tretinoin & retinoid can be applied to the neck, chest, & decollete areas. Neck areas are more sensitive compared to the face, so start slowly & titrate upwards.

*Retinoids can be used on conditions like poikiloderma (neck discolouration). They are marginally effective at best.

Can tretinoin be used for dark circles?

Yes, however you must be careful applying retinol or retinoids to the thinner, more sensitive eyelid skin. Start off with short contact tretinoin therapy, here is how-

• Apply a small amount to the area.
• Wash off within 15 minutes
• Repeat nightly.
• Reduce the amount of tretinoin & contact time if there is any skin irritation.

Though tretinoin can be used around the eyes, it is far easier to modulate retinol compared to more powerful retinoids .

Can this be used in pregnancy?

Retinoids such as tretinoin, adapalene, & retinol are not compatible with pregnancy as they are classed as category X. They have been shown to cause birth defects in rats at super high doses.

Compatible pigment correctors include: niacinamide, ascorbic acid, azelaic acid, AHAs, flavonoids, & botanicals such as licorice root extract. Pregnancy associated melasma can be safely treated with glycolic acid peels & pico lasers.

Retinol vs tretinoin, which is better?

Tretinoin is stronger, however not necessarily better. If you have sensitive skin, or if you use a whole heap of actives, you are better served with retinol, with occasional use of tretinoin. An example is-

• Retinol monday to friday nights (good formulation that also moisturizes)
• Tretinoin 0.05% weekends

What is a step up from tretinoin?

More powerful (but not necessarily better) retinoids include –

Adapalene: used mainly for acne, but has anti-aging potential.

Trifarotene: acne medication that is a fourth generation RAR gamma agonist. To date the most powerful topical retinoid, hampered by almost universal skin irritation. A favorite personal recommendation amongst dermatologists. Hard to modulate for 90% of patients.

Tazarotene: third generation retinoid, with ant-acne action.

Recommendations: Optimize your retinoid application including absorption prior to considering other options, especially if you are using a plethora of other skin care products. In the context of melasma & pigmentation, there are other better options for pigmentation inhibition. Our clinicians will guide you.

What is a step down from tretinoin?

The four main retinoids include retinol, retinyl palmitate, retinaldehyde & bakuchiol. This group requires conversion to retinoic acid for activity.

For melasma, we recommend using one of the four listed (favorite is retinol). Weaker agents does not necessarily mean it is less effective. The converse applies as if you use more powerful prescription retinoids, skin irritation may ensure.

Should I use tretinoin for both anti-aging & anti-pigment roles?

It depends on what you perceive as more important- an anti-aging routine that will not give you results (remember retinoids are best used as mitigation, not treatment), or if you would like to see a reduction of pigment*. If it is the latter, other agents are better.

*This is not a rule set in stone, you can combine retinoids with pigment correctors (eg. Triluma), however this requires more guidance as compared to stand alone ingredients. Our clinicians can guide you.

What is TriLuma?

TRI-LUMA (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) Cream is used to treat melasma. It contains a potent depigmenting agent, tretinoin & a corticosteroid preparation.

Tretinoin is premixed with TriLuma to potentiate the effects of hydroquinone, whilst steroids reduce the skin irritation from tretinoin & hydroquinone. This cream is highly effective for melasma, however its use should not extend beyond 8 to 12 weeks.

What are the side effects of tretinoin cream?

Side effects are vastly different from expected effects. Everyone will have adverse events to powerful retinoids, depending on their skin’s threshold for irritation. This is innate, modified by exogenous factors such as the concentration of tretinoin, application frequency & skin barrier function.

Side effects include:

• Burning, itching, stinging, scaling, or redness of the skin.
• Chapping or slight peeling of the skin (mild to moderate)
• Darkening of pigment (post inflammatory)
• Lightening of normal skin color.
• Lightening of treated areas of dark skin (the wanted effects!)
• Purging

Will my skin purge from tretinoin?

Possibly, but this is short lived. You can reduce the chances of purging by-

• Slow titration of cream- apply twice a week, increase as tolerated
• Dilution of cream ½ with moisturizer
• Using a weaker formulation

Skin purging is short lived, 1-3 weeks, so hang in there.

How do I get a prescription of tretinoin?

Book an appointment with your clinician, alternatively consult our physicians at The Melasma Clinic in Brisbane or Sydney.

What are retinoic acid peels & how powerful are they?

Clinicians at The Melasma Clinic employ retinoid peels to treat pigmentary disorders. As a guide these peels are 20 to 100 times more powerful than tretinoin. We use 1-7% retinoic acid to deliver super potent concentrations of vitamin A into the deeper layers of skin.

Retinoic acid peels

• Used for pigmentation, fine lines, anti-aging, oily skin, acne prone skin
• Application in clinic, wash off between 1-12 hours post peel
• Peeling for 2-8 days
• Classed as a superficial peel
• Great for melasma & pigment prevention, especially after lasers