Can Anyone Use Retin-A?

Recently a long-time reader of this blog (thank you Louise for all your support!) asked me to address the issue of Retin-A use in my blog from a different angle than I have before.  So far the posts I’ve written about Retin-A have been an overview post on the subject (All About Retinol) and another post explaining why Retin-A remains the anti-aging superstar ingredient that it is (Back in Vogue: Retin-A).  Though this post will have some overlap with my past posts about Retin-A and retinol I do hope that this latest post will help explain how anyone can use Retin-A or retinol effectively and just how to do that.

I think it is best to start this post with a summary – what does Retin-A do and what is the difference between the different Vitamin A derived ingredients we see in skincare products?  Dr. Leslie Baumann does a good job of breaking things down:

First and foremost, retinoids speed the rate at which skin cells turn over, which means they thin the layer of dead skin cells and help keep healthy, younger-looking cells on the surface. Retinoids also promote the skin to produce more collagen while preventing the breakdown of existing collagen.This thickens the dermal layer of skin and helps minimize the appearance of lines and wrinkles. Here’s the lowdown on the different members of the retinoid family, which are all derivatives of vitamin A.

Beta carotene: If you eat too many carrots and your skin turns orangey yellow, it’s because you’ve ODed on beta carotene. (Don’t worry, it’s actually good for you.) This is a great antioxidant, so it’s important to get beta carotene from food. Don’t waste your money on topical creams with carrots or beta carotene because it does not absorb when applied to the skin.

2.Tretinoin (Retin-A): Perhaps the best known retinoid (and the gold standard for skin improvement), tretinoin got its start as an acne treatment before its inventor, Albert Kligman, MD, realized that patients on the medication had less wrinkles than those who were not. Dr. Kligman then developed Renova, a tretinoin cream that got FDA approval for the treatment of wrinkles. A little fact: Tretinoin does not cause sun sensitivity, however it is less effective when exposed to UV light, and this is why it’s best used at night. Other brand names of tretinoin now include Atralin (formulated with hydrating glycerin), Refissa, and Retin-A Micro.

3.Adapalene: This is considered a second-generation retinoid because its chemical structure is different than naturally occurring retinoids. The brand name is Differin, and it is more stable when exposed to the sun and less irritating. The prescription EpiDuo contains adapalene and benzoyl peroxide to help fight acne. In recent news, adapalene is now available as a generic.

4.Tazarotene: A third-generation retinoid, this is stronger than adapalene, less irritating and more sun-stable. I like it for patients who have been able to tolerate tretinoin and/or adapalene without any problems.

5.Retinol: This is the over-the-counter version of tretinoin, but the big drawback is that it’s very unstable, and the product packaging is crucial for its effectiveness. Johnson & Johnson has had the patent on retinol packaging, which is why my favorite OTC retinols are from RoC and Neutrogena. It’s much weaker than tretinoin, but studies do show it works to improve wrinkles. I like to start my patients on retinol and then work them up to tretinoin, and then tazarotene.

6.Retinyl esters (retinyl palmitate and retinyl linoleate): These ingredients are broken down into retinol once they’re applied to the skin. However, it takes time for them to absorb which is why there’s some controversy surrounding retinyl palmitate—based on a report by the Environmental Working Group. They aren’t irritating (because they don’t really absorb), but they don’t really work, so I say skip them.

7.Retinaldehyde: This penetrates better than retinyl esters, but not as well as retinol (which is why it’s less irritating). If you’re looking for results and bang for your buck, stick with retinol or a prescription.

(From Retinoids: An Essential Ingredient for “Wrinkled” Skin – Skin Type Solutions LibraryTips)

As great as Retin-A is for the skin many people cannot use it because it causes them too much irritation.  The Vogue article The Return to Retinol explains:

The thing is, Retin-A and its various prescription descendants (Renova, Tazorac, Differin)—may have launched a thousand lineless faces, but they also launched as many irritated ones: scaly, red, angry. In those early days (fifteen years ago), retinoids could be used only at night because of their sensitivity to light; they could make skin extra-sensitive and made time in the sun, even incidental exposure, a cardinal sin. “Everyone was really excited from the beginning, but the big issues were dryness and irritation—mostly because people would apply too much,” says dermatologist Fredric Brandt, M.D., the New York– and Miami-based skin-care Svengali who has thousands of seemingly ageless women in his thrall (retinoid enthusiasts Madonna and Gwyneth Paltrow included). But even when skin wasn’t in outright crisis mode, a telltale sort of “retinoid face” could develop: spookily taut and shiny, like Barbie plastic. This is because the retinoic-acid molecule works a little too well: It’s so tiny it can penetrate all the layers of the skin, prompting extra-speedy cell turnover and exfoliation in the process. “You’re helping fix photo-aging, brown spots, acne, roughness, and collagen breakdown,” says Brandt. Miraculous, yes; gentle, no.

So what can you do in order to prevent irritation if you want to use Retin-A (and I personally strongly recommend Retin-A for those people who want to combat the signs of aging or who have acne and have tried numerous other anti-acne treatments to no avail), but cannot live with flaky, irritated, and red skin?  Start off slowly – use a retinol, an OTC product, before using a prescription product. You can try a product that is meant for sensitive skin like ROC Retinol Correction Sensitive Night Cream  (truthfully I don’t know how well this product works, but it worth a try if you have sensitive skin or are wary of trying a stronger product)  first before working your way up to a stronger product.  In a sense you will prepare your skin to tolerate stronger prescription products in the future.  According to Dr. Ellen Marmur in her book Simple Skin Beauty there are a few other ways to prevent skin irritation associated with using Retin-A (pages 278-279):

Prescription retinoids are the strongest and most effective form of retinoic acid.  Over-the-counter products contain milder vitamin A analogs; either retinol or retinyl palmitate (retinyl palmitate beign the weakest).  In order to have an effect on retinoid receptors, these must be converted to retinoic acid inside the body, and that conversion may not happen with the trace amount of low-strength vitamin A contained in a beauty product.  Although the results are therefore inconsistent, an OTC retinol might be worth at try if you’re skittish about using a prescription medication or if you have especially sensitive skin.  Stabilized, high-strength retinol may be somewhat effective, but look for one that states the percentage of retinol on the label.  Otherwise there’s probably just a tiny, ineffectual amount in the product.  (Personally, I would rather use a prescription retinoid with a percentage of medication that I know works.)

Side Effects:  Retinoic acid is a drug and there are risks associated with its use.  Since it decreases sebum (remember, this is still an acne medication), it makes the skin extremely dry.  (If that’s the case for you, applying moisturizer on top of retinoic acid is the answer, and it won’t dilute its potency.)  It makes the skin photosensitive, so daily sunscreen is a must – which is also why retinoic acid should be used at night.  It tends to irritate even moderately sensitive skin, so be careful not to overdo exfoliants such as glycolic acids (one a week is plenty).  For the same reason, be sure to stop using retinoids three to five days before having any skin procedures done, from simple waxing and facials to medical peels or lasers.  For those who have a hard time tolerating even a low-dose prescription retinoid, I recommend trying short-term applications: apply a pea-size amount over the whole face and neck, leave it on for fifteen minutes, then rinse it off.  You may get the same benefits as wearing it overnight.

Another thing to keep in mind is that even though having flaky and red skin is a side effect from using Retin-A it is a temporary one.  Your skin will get used to the product and those skin irritations will gradually disappear.  But if you live in a cold or dry climate your skin might constantly feel dry with Retin-A use.  Simply use a moisturizer twice daily at least or more if necessary to combat this dryness.  Be sure to wait about 10 or 15 minutes after applying your Retin-A before applying your moisturizer on top so that you allow the Retin-A to absorb properly into your skin.  Lastly, keep in mind that Retin-A comes in a wide variety of formulations.  Refissa, for instance, is a 0.05% tretinoin cream that is buffered so that it causes much less irritation for the user.  Many people do not peel at all when they use this product.

Summary of Different Ways to Prevent Irritation When Using Retin-A:

• Only use a pea size amount for your entire face.  There is no need to use more.
• Start off slow – use your Retin-A only twice a week or every other night for at least two weeks before determining if you want to use it more often.  For some people using Retin-A twice a week is enough.
• If you are wary of using a prescription product start off with an OTC product.  Be sure to follow the manufacturer’s instructions for use.  After using a product like this for a few months you can move on to prescription one.
• Ask for a prescription buffered product like Refissa if you know your skin is reactive and/or dry.
• Work through the initial phase of irritation. That means be patient – you’ll see results in about three months.  Don’t give up on the product before then.  If you start and then stop and then start again using Retin-A your skin will get stuck in phase one of use.  Simply put your skin will constantly be irritated and red.
• Use a moisturizer on top of your Retin-A.  Some of my favorite moisturizers to combine with Retin-A use are the renewal products from Epionce.  Be sure to wait at least 10 minutes after applying your Retin-A before applying a moisturizer on top.
• Avoid irritating your skin further by overusing other facial exfoliating products like glycolic acid.  Products with Vitamin C can even be too irritating for some people if they are using Retin-A.
• Use sun protection daily.

OTC Products 

I don’t want to call this recommended products since I haven’t tried any of them, but all the products below come from reputable companies:

• PCA Intensive Age Refining Treatment
• PCA Intensive Clarity Treatment
• Skinceuticals Retinol 0.5
• Skinceuticals Retinol 1.0
• La Roche Posay Redermic [R]
• Neutrogena Rapid Wrinkle Repair Serum
• ROC Retinol Correction Deep Wrinkle Night Cream

Sources and Further Reading:

• Retinol: When to Use It, and When to Avoid It – WebMD
• Anti-Aging All-Stars: 5 Ingredients That Pack A Punch – Allure
• Retinol Skin Tips From Big Brother’s Dr. Will – Allure
• Retinol Cream: Your Skin’s New Best Friend – O, The Oprah Magazine
• A New Generation of Retinoids and Dr. Diana Howard on the Benefits of Retinol – The International Dermal Institute
• Vitamin A: the Gold Standard for Extrinsic Aging – The New Ideal in Skin Health by Dr. Carl Thornfeldt and Krista Bourne, LE – pages 153- 156
• The Only Proven Wrinkle Reducers and Age Fighters: Retinoids – The Mind-Beauty Connection by Dr. Amy Wechsler – pages 29-30

Image from anti-aging-skin-care-guide.com