Tretinoin: The Perfect Anti-Ageing Solution?

Acne and skin ageing are the daily consultations of every dermatologist since everyone wants to have clean and healthy skin nowadays. 

Tretinoin has been for years one of the best treatments to fight ageing signs and inflammatory conditions, providing visible results in a short time (compared to other drugs). 

Also called retinoic acid, it comes from vitamin A (retinol) and belongs to the retinoid group. Let's find out its key points; actual benefits and effectiveness rate proved by science.

What is tretinoin, and what is it used for? 

Tretinoin is the acid form of retinol (vitamin A), a drug with comedolytic action (destroys comedones, a.k.a blackheads) to normalise the skin renewal or desquamation to avoid the follicle-clogging while having anti-inflammatory properties.

It is medically indicated in conditions such as non-inflammatory (comedones) and inflammatory (pustules and papules) lesions in mild to moderate acne vulgaris, as well as to improve the signs of sun-induced ageing (photoaging).

But retinoids are not only limited to the skin, as they are helpful in several processes due to their immunomodulatory, chemopreventive, steroid antagonist, and new blood vessel growth (angiogenesis) properties.

It has been used as a cancer treatment, especially in leukaemia, chromosomal disorders, psoriasis, psoriasiform processes such as pityriasis rubra pilaris, and premalignant and malignant skin conditions. Although some are off-label uses (not FDA approved), tretinoin represents a drug with an excellent not-fully-understood potential to date.

What does tretinoin do for the skin?

Here we can get a little dense as the working mechanism of every drug is complex, but we will explain in a short and easy-to-understand way.

There are nuclear-type receptors within each cell. These are proteins responsible for recognising molecules and other products to produce a specific effect. 

Topical tretinoin binds to two types of nuclear receptors once applied to the skin; retinoic acid receptors (RAR) and retinoid X receptors (RXR).

This binding allows for different outcomes on cells such as:

1. Stopping inflammation (prevents the release of inflammatory substances). So it usually reduces the redness of pimples.
2. Increases the procollagen production to make collagen I (80% in photoaged skin), III and VII, and the collagen reorganisation in new tissue bundles. Ideal for aged skin.
3. Modifies the abnormal cycle of keratinocytes in acne through the detachment of the corneous layer cells. In short, it regulates skin cell activity, both in oily production and in its regeneration.
4. Increases the cells reproductive activity to boost the turnover of old cells to new ones to prevent comedones and improve blemishes (thus exfoliating).

How do I use tretinoin? 

Its use depends on what you are looking for and the severity of the lesions. Topical application is the most first used and recommended form, and it can be applied in gel or cream for:

• Treatment of acne vulgaris
• As a complementary treatment of photoaging

The topical administration consists of applying a thin layer daily, before bedtime, to the skin only on the affected areas. You need to keep the medication away from eyes, mouth, nasal creases, and mucous membranes. Dosages vary amongst different brands, but in general, the higher the dosage, the greater the exfoliative effect.

How to use

First, wash the skin with water and mild soap. Take a pea and apply a thin layer. Let dry without rubbing for 15-30 minutes. After use, wash your hands. Use it preferably before bedtime, and protect your skin by wearing sunscreen the following day.

An initial improvement can be noticed after 2-4 weeks of treatment, and the maximum effect is not reached until 6-8 weeks.

The orally taken form of tretinoin is called isotretinoin, a highly effective drug given orally in severe forms of acne such as moderate to severe cystic acne. It is indicated orally since its topical application produces the opposite effect; to cancel or diminish sebum control.

How long does it take tretinoin to work?

You may see results after the first month of use, and its daily application can be extended up to two years if needed.

How effective is it really?

Treatment should be maintained for at least two years to treat the signs of photoaging such as fine wrinkles or hyperpigmented spots, as it has been shown that this long-term regimen improves 21% and 9% of them, respectively. Of course, the more advanced the ageing, the lower the response rate or noticeable changes.

The improvement can be highlighted as follows:

• 1 month for coarse wrinkling
• 2 months for fine wrinkling
• 4 months for blemishes such as mottled hyperpigmentation, sallowness, and lentigines. 

However, tretinoin is not as incredible as it seems. It is possible that the treatment and its skin response may become dose-dependent over time and that upon discontinuation, acne, fine wrinkles, and rough appearance may reappear again.

For example, two 12-week treatment regimens with tretinoin (0.1% and 0.025%) can reduce blackheads by 80% and 35%, respectively. The same happens with other retinoids such as adapalene, whose efficacy is higher when used at 0.3% than 0.1%. So, in short, its effectiveness increases as its dosage does.

How does it compare with non-medicine skincare products?

Its efficacy compared to other products depends on the intended use. Studies show that:

• 0.1% tretinoin is highly effective in melasma (hyperpigmented spots), reducing 36% of pigment after use versus a 50% increase with a standard cream after 9 months of continued treatment.
• Treatment with tretinoin emollient cream 0.05% for 2 years is much more effective in improving the appearance of fine wrinkles than a generic emollient cream by 20%.
• It reduces both inflammatory and non-inflammatory acne by 40% to 70% compared to generic creams. 
• 0.1% tretinoin is also effective at a ratio of 83% vs 32% vehicle cream against inflammatory severe acne lesions. 

However, natural treatments such as aloe vera may be just as effective as tretinoin when used at 50% due to its anti-bacterial and anti-inflammatory properties. The anti-inflammatory effect may be enhanced when combined, but further testing is still required. 

Conclusion

Tretinoin is the acid form of vitamin A with multiple working mechanisms in cells, so many that we fall short when we talk about its action here.

Concerning the skin, tretinoin was the first retinoid for treating acne and the photoaged skin, and it is still a significant mainstay against both today.

Its daily use can provide benefits that depend on how long the treatment lasts, doses and condition severity. Being more effective in cystic or pustular acne but less so in advanced photoaging.

As mentioned, tretinoin is not a magic medical compound. On the contrary, it is like any other drug with side effects such as irritation, redness, and unsuccessful cases. Many patients have relapses of acne and wrinkles, while its daily topical application may not work in others. This is when oral isotretinoin takes over.

Tretinoin versus non-medical compounds appears to be more effective or equal when combined. However, more tests and studies are needed to prove it.

If you are considering using tretinoin, keep in mind that you must do so under medical supervision and according to the instructions of a dermatologist after a thorough evaluation of your skin.

Tretinoin is not intended for everyone, but you will likely see good results with continuous use if you are a potential candidate for it.