Retinoids for acne: which to use and how

What do retinoids do for acne?

Retinoids are medicines derived from vitamin A. Acne develops when hair follicles become blocked with excess oil and dead skin cells. Bacteria can grow inside those blocked follicles, causing inflammation and pus. Topical retinoids help clear the blockage and reduce inflammation; adapalene also stops pimples forming beneath the skin's surface. Tretinoin increases production of new skin cells and unclogs pores. These treatments control acne rather than permanently curing it, so treatment is not necessarily finished when the visible spots clear.2345

Which retinoid should you use?

If irritation is a concern, adapalene is generally less irritating than tretinoin. Texture also matters: creams are generally the least irritating retinoid formulations. Gels are less noticeable on skin, which is useful for a product not hired as makeup. Choose the medicine and formulation together rather than treating the ingredient name as the whole decision.2

Adapalene 0.1% cream is a first line option for mild to moderate comedonal acne in the NHS Highland formulary. The same formulary includes both strengths of the adapalene and benzoyl peroxide gel for mild to moderate acne. Use the strength prescribed or directed on your package; increasing the amount or frequency of adapalene does not speed up results.46

How are retinoids used for acne treatment?

1. 1Read the package or prescription directions. Adapalene and tretinoin are usually used once daily at bedtime; follow any different schedule your prescriber gives you.
2. 2Wash gently with a mild cleanser. Pat dry before adapalene; for tretinoin, let the skin dry as directed. Avoid abrasive or drying cleansers.
3. 3Apply a thin layer over the affected area. Adapalene goes over the whole affected area, not just individual pimples. Use clean fingertips for creams and gels.
4. 4Keep the medicine away from the eyes and mouth. Follow the product's instructions for other areas to avoid, including the nose and lips.
5. 5Use moisturizer to help with dryness. If adapalene irritates your skin, ask your doctor whether to apply it less often.
6. 6Wear sunscreen and protective clothing during the day. Avoid unnecessary or prolonged sun exposure and tanning beds.

Wash acne prone skin twice daily, remove makeup at the end of the day and avoid scrubbing. Noncomedogenic skincare and makeup are sensible choices because they are designed not to clog pores, even if the word looks like it needs its own instruction leaflet. Do not pick or squeeze spots, because that can cause scars.3

Can you combine retinoids with other acne treatments?

Combining treatments with different actions can improve acne results. Benzoyl peroxide reduces bacteria, while retinoids unclog pores and reduce inflammation. A prescribed combination can therefore address more than one part of acne. Antibiotics used for acne should be accompanied by benzoyl peroxide to reduce antibiotic resistance, and oral antibiotic use should be limited.17

Combination treatment is not permission to layer every acne product together. With tretinoin, discuss benzoyl peroxide, other topical medicines and hair removal products with your prescriber before adding them. Harsh or drying skincare can increase irritation with adapalene. Do not use hot wax on an area being treated with adapalene.45

How long do retinoids take to work?

Adapalene can bring previously unseen pimples to the surface during the first few weeks. Its full benefit can take 8 to 12 weeks or longer. With tretinoin, acne can initially worsen during the first 7 to 10 days; spots should begin improving after 2 to 3 weeks, though sometimes this takes more than 6 weeks. A fuller response to topical retinoids can take 12 weeks or longer.245

Continue as directed through an early increase in spots, but do not treat significant irritation as something to push through. Improvement from tretinoin can gradually disappear after stopping. Topical retinoids can also be used as ongoing acne treatment after a course of oral isotretinoin, the retinoid taken by mouth.245

Who should be careful, and when should you stop?

• Dryness, redness, peeling, burning and stinging can occur. Contact your prescriber if symptoms are severe or persistent; adapalene irritation is common during the first 2 to 4 weeks.
• Do not apply adapalene to broken, sunburned or eczema affected skin until it has healed. Tretinoin also should not go on sunburned or eczema affected areas.
• Stop applying the medicine and seek urgent help for suspected serious allergy. Breathing difficulty or swelling of the face, lips, tongue or throat needs emergency care.
• With tretinoin, call your doctor immediately for hives, a rash, itching, or pain or discomfort at the application site.
• Tell your prescriber about existing skin conditions, allergies and all medicines and skincare you use. Adapalene is used for adults and children aged 12 and older; age limits depend on the medicine.

Avoid topical retinoids during pregnancy and discuss pregnancy plans with your prescriber before starting. If you become pregnant while using adapalene or tretinoin, call your doctor. Breastfeeding advice differs between medicines and local prescribing guidance: NHS Highland advises avoiding these treatments, while adapalene drug information includes precautions for breastfeeding use. Discuss the exact medicine before using it while breastfeeding.456

When does acne need a doctor?

See a doctor if self treatment is not helping, you have many spots, deep painful lumps or scarring, or acne is affecting your mental health. Hot, swollen skin with redness can signal infection and also needs assessment; redness can be harder to see on brown and black skin. Severe acne or acne that has not responded to standard topical or oral treatment can need oral isotretinoin rather than another topical retinoid alone.13