Tretinoin for acne vulgaris: how to use it

What does tretinoin do for acne?

Acne starts when excess oil and dead skin cells plug a hair follicle, the opening where a hair grows. A plug near the surface forms a whitehead or blackhead. Bacteria in blocked follicles can contribute to inflammation and pus. Cleaning the surface does not remove the blockage inside the follicle. Tretinoin belongs to the retinoid family of medicines derived from vitamin A. It increases production of new skin cells and opens blocked pores. Retinoids can also help other acne creams and gels work better.345

Who is tretinoin suitable for?

Tretinoin is an option for acne with blocked pores and inflamed spots. Topical treatment, meaning medicine applied to the skin, works best for mild to moderate acne. More serious acne can need a topical treatment alongside another medicine. A clinician should assess the types of spots and where they occur before choosing treatment. Extensive chest or back acne needs assessment rather than simply covering a larger area with tretinoin. Topical retinoids are not suitable for treating large areas of the body.12

Retinoids also help lighten dark marks left after acne clears. These marks are called postinflammatory hyperpigmentation and are especially common in skin of colour. A dark mark is not the same thing as an indented scar. Acne treatment aims to clear existing spots, prevent new breakouts and prevent scars; seek treatment for scarring acne rather than waiting for tretinoin to fix established damage.12

Which strength and formula should you use?

Use the strength and formula your prescriber selects, with the directions for that particular product. Tretinoin comes as a cream, gel or lotion. Across topical retinoid formulations, creams are generally the least irritating and gels the least noticeable on the skin. Previous irritation matters when choosing treatment: tell your dermatologist which retinoid you tried and what happened. Irritation does not usually mean an allergy, and a dermatologist can sometimes adjust treatment so a retinoid remains an option.12

How to apply tretinoin at night

1. 1Wash your hands and affected skin with a mild cleanser and water. Avoid abrasive or drying soap.
2. 2Let the skin dry. General retinoid guidance advises waiting 20 to 30 minutes after washing; follow your product's directions.
3. 3If dryness is a problem, use a moisturizer that will not clog pores after washing, then apply the retinoid 20 to 30 minutes later.
4. 4Use clean fingertips to spread a thin layer over the affected area. Keep tretinoin away from eyes, ears, mouth and nose corners. Do not apply it to sunburn or eczema.
5. 5Use tretinoin at bedtime as prescribed, usually daily. Do not increase the amount or frequency yourself.

What should your daytime routine include?

Use a gentle cleanser and moisturizer as needed. Choose sunscreen with SPF 30 or higher, broad spectrum protection and water resistance. Broad spectrum protection covers both UVA and UVB rays. Apply sunscreen after other skincare and before makeup, 15 minutes before going outdoors. Protect exposed skin with clothing and shade too. Retinoids can make skin more sensitive to sunlight, so avoid tanning beds and unnecessary prolonged sun exposure. Wind and cold can also irritate treated skin.45

Wash acne affected skin twice daily rather than repeatedly trying to remove oil. Use lukewarm water and avoid scrubbing, which can worsen irritation. Remove makeup before bed. Noncomedogenic skincare and makeup are less likely to block pores, even if the word takes up half the label. If dryness is a problem, a fragrance free, water based moisturizer is an option.3

How long does tretinoin take to work?

Acne can worsen during the first 7 to 10 days of tretinoin use. Some spots begin improving after 2 to 3 weeks, while others take longer than 6 weeks. For acne treatment generally, expect at least 6 to 8 weeks before seeing fewer breakouts. Topical retinoids can take 12 weeks or longer to show improvement. Treat those early changes as part of a longer treatment period, not a deadline for clear skin.124

Switching skincare too often can leave you with irritation and no clear sense of what helps. Continue the prescribed plan unless side effects require medical advice. Once acne is controlled, a dermatologist can recommend a retinoid as maintenance treatment to help keep skin clear.25

Can you use other acne treatments with tretinoin?

A dermatologist can combine acne medicines to target different causes of breakouts. Benzoyl peroxide reduces acne causing bacteria, while topical antibiotics reduce bacteria and inflammation. Prescription combinations can contain a retinoid with benzoyl peroxide or an antibiotic. When topical antibiotics are prescribed, benzoyl peroxide is included in the treatment plan to reduce antibiotic resistance, meaning bacteria become less responsive to treatment. Do not add benzoyl peroxide, salicylic acid or other topical medicines to tretinoin without checking with your prescriber.24

What side effects need attention?

Dryness, redness, peeling, burning and stinging can occur. Tell your doctor about severe or persistent symptoms. Call immediately for rash, hives, itching, or pain at the treatment area. Do not dismiss pain as ordinary early worsening. With your dermatologist's help, irritation can be managed by using a smaller amount, applying less often or applying moisturizer first. Avoid scrubs and overusing exfoliating products: irritation can make useful acne treatments harder to tolerate.24

Pregnancy, breastfeeding and other precautions

Do not use topical tretinoin during pregnancy or while trying to become pregnant. Discuss an alternative acne treatment before starting or continuing treatment; benzoyl peroxide and azelaic acid are among the options considered suitable during pregnancy. If you become pregnant while using tretinoin, call your doctor. Tell your prescriber if you are breastfeeding, have eczema or other skin conditions, or have medicine allergies. Review your medicines and supplements with your prescriber before starting.46

When should you see a doctor?

Arrange a review if acne is not improving with treatment, you have many spots, or spots are deep, painful or causing scars. Nodules and cysts need proper treatment to reduce scarring risk. Seek help for hot, swollen skin suggesting infection, or if acne affects your mental health. Do not pick or squeeze spots because this can cause scars. A clinician can confirm whether the breakouts are acne and whether your treatment needs changing.37

What if you miss an application?

Apply the missed dose when remembered unless the next dose is nearly due; then skip it. Never apply extra to compensate. Keep tretinoin tightly closed, at room temperature, away from heat, moisture and children.4