A practical approach to the use of retinoids in aging skin
Authors: Ellen C. Gendler
Journal: Journal of the American Academy of Dermatology (1998)

Although the benefits of topical retinoids in the management of various skin conditions are well known to dermatologists, the mechanics of getting patients started on an appropriate regimen are often quite difficult. Patients tend to glean snippets of information from magazines, news reports, and their friends but lack a real understanding of the way a retinoid program will affect them on a daily basis. Patients often have preconceived notions and unrealistic expectations regarding topical retinoids, which can impact their desire and ability to follow a routine. It behooves the prescribing physician to review in detail the actions of the topical retinoid, to establish realistic goals, and to prepare a routine that can be easily followed. Photoaged skin is characterized by mottled hyperpigmentation, fine and coarse wrinkles, skin roughness, telangiectasia, elastosis, and easy bruisability. Prior research has shown that tretinoin causes a reduction and more even distribution of melanin, facilitating improvements in mottled hyperpigmentation and lentigines.1Griffiths CEM Voorhees JJ The tretinoin story.Fitzpatrick's J Clin Dermatol. 1995; 3: 14-25Google Scholar Tretinoin use has been associated with normalization of epidermal atypia and with the formation of a band of new collagen in the upper dermis.2Yamamoto O Bhawan J Hara M et al.Keratinocyte degeneration in human facial skin: documentation of new ultrastructural markers for photodamage and their improvement during topical tretinoin therapy.Exp Dermatol. 1995; 4: 9-19Crossref PubMed Scopus (30) Google Scholar Within the epidermis, tretinoin temporarily stimulates proliferation of keratinocytes, resulting in increased shedding of corneocytes. Together, these functions result in smoothing of fine wrinkles and increased skin firmness. Tretinoin-induced angiogenesis helps to contribute to the rosy glow of the skin. The efficacy of retinoids in modulating cellular differentiation and proliferation led to the development of tretinoin emollient cream 0.05%, which is the only topical therapy approved by the Food and Drug Administration for the treatment of fine-line wrinkles, mottled hyperpigmentation, and skin roughness caused by aging and sun exposure. Tretinoin emollient cream 0.05% was formulated specifically for use with dry skin, with a unique, patented, water-in-oil emulsion for the base vehicle. Results of several double-blind, multicenter clinical trials comparing tretinoin emollient cream with its vehicle indicate that tretinoin is effective in treating the cutaneous manifestations of photoaging. Consistent use of tretinoin for 6 months led to a significant reduction of fine wrinkles, mottled hyperpigmentation, and skin roughness as compared with placebo (Fig. 1). The vast majority of patients (83%) and investigators (78%) reported overall global improvement with tretinoin use (Fig. 2).3Kligman AM Grove GL Hirose R et al.Topical tretinoin for photoaged skin.J Am Acad Dermatol. 1986; 15: 836-839Abstract Full Text PDF PubMed Scopus (556) Google Scholar, 4Weiss JS Ellis CN Headington JT et al.Treatment of photodamaged facial skin with topical tretinoin.JAMA. 1988; 259: 527-532Crossref PubMed Scopus (448) Google Scholar, 5Olsen EA Katz HI Levine N et al.Tretinoin emollient cream: a new therapy for photodamaged skin.J Am Acad Dermatol. 1992; 26: 215-224Abstract Full Text PDF PubMed Scopus (158) Google Scholar, 6Weinstein GD Nigra TP Pochi PE et al.Topical tretinoin for treatment of photodamaged skin: a multicenter study.Arch Dermatol. 1991; 127: 659-665Crossref PubMed Scopus (250) Google Scholar Fig. 2Tretinoin emollient cream photoaging trials.View Large Image Figure ViewerDownload (PPT)The effects of tretinoin emollient cream on fine-line wrinkling and mottled hyperpigmentation after 24 weeks of therapy may be seen in Figs. 3 and 4, respectively. Fig. 3Tretinoin emollient cream, 0.05%: effect on fine-line wrinkles. A , Before; B , after.View Large Image Figure ViewerDownload (PPT) Fig. 4Tretinoin emollient cream, 0.05%: effect on mottled hyperpigmentation. A , Before; B , after.View Large Image Figure ViewerDownload (PPT) It is important to carefully select the most appropriate candidates for topical methods of skin rejuvenation. The best candidates include patients who are able to integrate tretinoin into their comprehensive skin care regimen and who are willing to commit to a lifelong avoidance of sun exposure. Appropriate candidates must also understand and appreciate that the beneficial manifestations of topical therapy may not become apparent for months; ideally, these candidates are also willing to tolerate the transient mild irritation sometimes associated with the use of topical therapies. Clinicians can select those patients who might benefit from topical tretinoin therapy based on their degree of photodamage. Patients with more severe manifestations might require surgical interventions; however, these patients also show the greatest improvement from the use of topical therapies. In contrast, patients with mild-to-moderate manifestations will experience subtle incremental improvements over time. It is imperative that clinicians provide each patient with an opportunity to discuss the treatment, dispel any misconceptions, and develop a realistic skin care regimen. One method for selecting appropriate patients is to perform an overall skin evaluation during the initial consultation. The use of a Wood's lamp illustrates the extent of the damage to both the patient and clinician; this technique can also help convince a patient to adhere to the prescribed skin care regimen. Patients need to comprehend that, although topical tretinoin therapy can improve and possibly reverse some of the damage caused by overexposure to the sun, the benefits of the therapy are negated if the patient continues to sunbathe. It is also essential that patients who are considering topical tretinoin therapy are willing to consistently use broad-spectrum sunscreens that shield against both UVA and UVB. Currently, there are several sunscreens in the United States that contain avobenzone (Parsol 1789), which was recently approved by the Food and Drug Administration. Sunblocks containing micronized zinc oxide and titanium dioxide are effective, although patients are reluctant to use these occlusive products as cosmetics. It is helpful for clinicians to provide patients with a written list of appropriate sun products. Adherence to a comprehensive skin care regimen that includes topical tretinoin therapy is best facilitated with an open patient-physician discussion regarding the patient's often unrealistic expectations. Patients must understand that the benefits of the product may not be clinically apparent for a few months. Patients using tretinoin emollient cream 0.05% can expect visible improvement in skin smoothness and experience a tightening of the skin within 2 to 4 weeks after treatment initiation. Decreases in fine wrinkles and mottled hyperpigmentation may first become apparent after 2 to 4 months of therapy; however, some patients may not see visible changes for up to 6 months after treatment onset. Improvements in coarse wrinkles require at least 6 months of treatment. Tretinoin emollient cream 0.05% is applied daily at bedtime to the entire face, after it has been cleaned, avoiding the eyes. Patients with sensitive skin are recommended to begin the treatment with pea-sized applications on alternate nights or every third night for the first 1 to 2 weeks. Patients who experience mild irritation, redness, or dryness are instructed to reduce the amount of medication applied to the skin until accommodation to a nightly regimen is accomplished. It is helpful to assess each patient's daily cleansing and moisturizing routine before establishing their most appropriate treatment regimen. For example, patients may need to be switched to milder foaming cleansers from bar soaps; exfoliants and scrubs should be avoided. Toners may also need to be removed from the daily skin care regimen. It is not recommended to use moisturizer with tretinoin at night; however, daytime moisturizers with sunscreen are important components of the recommended regimen. Clinicians must account for the climate, season, and skin sensitivity of each patient when devising the skin care regimen (Table I). Table IOptimizing topical therapyIndividualize facial cleansingDecrease frequency of application if irritation occursNo concurrent topical products applied with tretinoinIntegrate into comprehensive skin care regimen Morning: use moisturizers and sunscreens Avoid exfoliants, scrubs, and toners Open table in a new tab Physicians can anticipate inquiries from the patients during the first few weeks of tretinoin treatment regarding the mild and transient irritation; patients who receive effective pretreatment counseling will have fewer inquiries. Written handout material for patients can also minimize the inquiries during the accommodation phase of the treatment. Follow-up clinical examinations can be scheduled for 2 to 3 months after treatment begins, when the initial benefits of tretinoin have become apparent. Similarly, comparisons to pretreatment photographs are indicated 6 months after treatment initiation, when patients may become frustrated at a perceived plateau in their therapy. Additional treatment modalities (such as chemical peels, collagen or botulinum toxin injections, or laser therapy) may be discussed at that visit. Obviously, the use of topical retinoids will not lead to perfect skin. However, for those patients who demonstrate a commitment to sun avoidance, topical retinoids can be a helpful tool in the armamentarium to combat the ravages of photoaging.