Although effective for different types of acne, topical retinoids commonly cause adverse effects. These are generally mild in severity and usually during the start of therapy. Within the first month of treatment many patients experience a “retinoid dermatitis.” This may consist of erythema, burning, scaling, pruritus, and dryness. These effects tend to decrease with continued use. Detailed instructions on appropriate use of retinoids can help limit any adverse side effects and enhance tolerability (Table 3). In general, a pea-sized amount should be applied evenly over the entire face. If any medicine is visible on the skin after application too much was applied and additional irritation may ensue. Instructing patients to apply their retinoid to dry skin can also minimize retinoid dermatitis. Patients should be advised to wait 15 minutes after washing the face to apply a topical retinoid. Wet skin enhances the penetration of the retinoid into the dermis, thus exacerbating irritation. A gradual increase in application frequency can also help to minimize irritation. The patient should apply the retinoid starting every other night or every third evening for the
Table 3 Patient Information About Topical Retinoids
When initiating treatment, apply topical retinoids every second or third day for the first couple weeks and gradually increase to once-daily application Tretinoin must be applied at night
Wait 15 minutes after washing face to apply the retinoid Apply a pea-sized amount to cover the entire face
Do not use a benzoyl peroxide product at the same time of day as retinoid application (concomitant use all right with adapalene)
Redness, burning, scaling, pruritus, and dryness may occur, especially during the first month of treatment. These side effects generally decrease with use A non-comedogenic moisturizer may be used to prevent dryness Photosensitivity may occur with all retinoids
Some patients experience a flare of their acne during the first few weeks of treatment
The above patient information regarding topical retinoid use can improve compliance and efficacy.
first one to two weeks of treatment. The patient can then gradually increase the frequency to nightly use as tolerated. Tolerance is often achieved in three to four weeks. It is important that the topical retinoid be applied at night-time for two reasons. Firstly, patients who use topical retinoids during the daytime notice increased sensitivity to ultraviolet (UV) light. Secondly, tretinoin is unstable when exposed to sunlight. When exposed to light, 50% of tretinoin is degraded in two hours (47). The synthetic formulations adapalene (47) and tazarotene (48) remain chemically stable when exposed to sunlight, and may be applied morning or evening. To combat irritation it is recommended that a non- comedogenic facial moisturizer be applied during the daytime. Some patients experience a pustular acne flare during the initial weeks of retinoid treatment that subsides with use. Patients should be warned of this possibility and encouraged to continue treatment through the exacerbation.