When I am planning acne treatment for new patients to the clinic, we have a discussion about the most effective management options based on the severity of their symptoms, what kinds of spots they are getting (e.g. blackheads, pustules, nodules, cysts) and what treatments they’ve already tried. Sometimes oral treatment is most appropriate, sometimes creams or gels (known as topical therapy) are most appropriate and often both are needed together in combination. Topical therapy of acne includes the use of agents that are available over the counter e.g. benzoyl peroxide and salicylic acid or via specialist prescription e.g. antibiotics, azelaic acid and retinoids.
So what are topical retinoids? In short, they are vitamin A derivatives. Examples include adapalene (Differin), isotretinoin (Isotrex) and tretinoin. They are possibly the most critical topical therapy for acne because they reduce blockage of the pores (the opening of the hair follicle onto the surface of the skin) and are also anti-inflammatory. As well as enhancing most acne treatment programmes, they can also help with maintaining control after discontinuation of oral therapy.
Retinoids are ideal for blackheads and, when used in combination with other agents, for most types of acne. Although they are a very useful tool in the management of acne, the use of topical retinoids may be limited by side effects such as dryness, peeling, redness and irritation. They have also been associated with photosensitivity i.e. causing the skin to be more sensitive to the sun.
These side effects can all be much easier to tolerate if the steps below are followed:
1. Use a gentle skin cleanser morning and evening. Apply to a wet face and rinse off with lukewarm water. Do not scrub vigorously.
2. Apply your retinoid cream at night before you go to bed. Do not apply it in the morning as it can make your skin more sensitive to the sun. Take precautions to avoid sunburn by applying a non-comedogenic, broad spectrum SPF50 sun protection moisturiser in the morning before applying your makeup or leaving the house.
3. Introduce it gradually. Start off by applying it twice per week at night. It is normal to have a bit of redness or peeling after a few days. After a couple of weeks, increase application to alternate nights if tolerated. This can subsequently be increased to every night after a further two to four weeks if you are tolerating treatment with minimal or no irritation.
4. If the skin irritation is severe, stop the prescription for a few days until it has settled before attempting to reintroduce it even more gradually.
5. Most people will eventually be able to apply their prescription cream every night without any ongoing discomfort, however some will only ever manage alternate nights or twice per week at the most. Do what you can – some treatment once or twice a week is usually better than none at all.
6. Apply the cream (or gel) in a very thin layer to cover all of the areas that you tend to get the acne, not just onto individual spots. The quantity really doesn’t have to be particularly large as this will just increase irritation.
7. Avoid the area directly around your eyes as the skin is more sensitive.
8. If your skin is dry or irritated, you can apply a moisturiser at night by layering it on top of your retinoid cream. Ideally you should wait 15 minutes or so between these steps to prevent the the retinoid being diluted by your moisturiser. Look for a moisturiser that is labelled non-comedogenic.
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