Retin A is an original. Acne fighter and wrinkle improver, it has a special place in the heart of dermatologists. And just like any product pioneer, eventually knock-offs appear as well as new derivatives in the ever-expanding world of "new and improved". However, consumers need to be aware that there IS now a difference in the variety of topical vitamin A treatments that resemble Retin A. Some of that is good, some bad, but it remains that an informed consumer is a happy consumer. With this in mind, let's learn about topical Vitamin A.

Retin A was developed more than 25 years ago as an acne treatment. It's actually a twisted form of the Vitamin A molecule. We use it not just for acne but for a wide variety of other skin concerns that respond to exfoliating agents and "keratolytics" (a product that removes a plug out of a hair follicle or sweat gland). Prior to the development of Retin A, dermatologists basically relied upon oral dosing of Vitamin A to help treat acne and a wide variety of other skin conditions. However, oral Vitamin A has problems with systemic overdosing and there were few standardized options for Vitamin A, much the way regular vitamins do not have FDA standardization today. One standardized prescription formulation went by the name of Aquasol A, unfortunately it is no longer on the market. And more importantly, not everyone could or should have to take pills on a daily indefinite basis.

WHAT'S VITAMIN A GOT TO DO WITH IT?

Exactly what does vitamin A do? By its very nature, vitamin A causes drying of the skin and peeling when too much is taken orally. There is a variety of different topical prescription and OTC vitamin A derivatives that make use of this side effect to treat a variety of skin concerns. These include:

• Acne
• Oily Skin
• Wrinkles
• Precancerous Skin Lesions (Actinic Keratoses)
• Flat Warts
• Psoriasis
• Keratosis Piliaris
• General thinning of incredibly thickened skin due to a variety of other skin disorders such as certain forms of ichthyoses, pityriasis rubra pilaris (PRP), mycosis fungoides (T-Cell Lymphoma of the skin), thickened palms and soles due to internal cancers, etc.

NOTHING replaces the activity that a vitamin A derivative has in the fight against comedonal (aka blackhead) forms of acne. All work in the same way to remove the keratin plugs that form black heads and to decrease the number of small inflammatory papules.

The exfoliating properties of tretinoin (and others) also is used for bleaching tough unwanted skin discoloration. In fact, generic tretinoin is one of the cornerstones of the Obagi system.

Tretinoin also has a place in smoothing out hair follicle bumps known as keratosis pilaris and helps fight tiny flat warts.

Topical Vitamin A has been suggested to help build collagen fibers within the dermis in addition to its more superficial exfoliating property. This is the basis for its use in minimizing the appearance of fine wrinkle lines.

THE BASES ARE LOADED

Creams hydrate. Gels dry. Solutions are meant for those oily individuals for whom the gels weren't drying enough. And ointments are REALLY heavy. Simple. Oily skin? You may need the gel, not the cream for additional drying benefits. Sensitive or dry skin that is still acne? You may need a specially formulated base such as Retin A Micro Gel (yes, I realize it's a gel, but it is supposed to be less irritating or drying).

EENIE, MEANIE, MINEY, MO

Having trouble trying to figure out what all of the various names and strengths of topical vitamin A creams are out there on the market? In recent years, Retin A has had competition in the forms of Differin gel and Avita gel and cream. These 2 are marketed as being less irritating and expensive that Retin A, but they are relatively similar. Recently, Retin A also became available as a generic. This does cause me concern, as Retin A is already an irritating product, and we don't know what is in the base cream that Retin A is suspended in, possibly causing it to be even more irritating. I do recommend to patients that if they have a choice, to skip the generic form of this particular product.

Here's some info to try to simplify it all:

Retin A
Indicated for Acne
Generic Name: Tretinoin Strengths:0.01% Gel; 0.025% Gel; 0.025% Cream; 0.05% Liquid; 0.05% Cream; 0.1% Cream; 0.1% Micro Gel

Avita
Indicated for Acne. As it's generic is tretinoin, similar skin rejuvenation use considered appropriate
Generic Name:
Strengths:

Differin
Indicated for Acne
Generic Name: Adapalene
Strengths: 0.1% Gel; 0.1% Solution

Tazorac
Indicated for Psoriasis and Acne. Good for those with chronically oily skin or severe blackhead form of acne. Pending indication for skin rejuvenation.
Generic Name:Tazarotene
Strengths: 0.1% Cream; 0.1% Gel; 0.05% Cream; 0.05% Gel

Renova
Generic Name: Tretinoin
Strengths: 0.05% Cream; 0.025% Cream

PLAY BY THE RULES

There is a reason most dermatologists will give a written instruction sheet when they prescribe an Rx version of a topical vitamin A cream/gel/ointment regardless of what the use. I can still vividly recall being a teenager and using Retin A, and of course doing everything I SHOULDN'T do which resulted in lots of redness, inflammation and pain.

The use of these products can have side effects you won't like if you don't listen to the doctor as well as to what your skin is telling you. In addition, many people mistakenly think that their OTC retinol and retinyl palmitate (usually used for skin rejuvenation) counterparts are going to be quite mild and irritation-free. This could not be further from the truth. You typically need to use all topical vitamin A products in a similar manner unless directed not to do so.

What to watch for

• Redness
• Burning/Stinging
• Peeling/Exfoliation
• Increased Sunburn Potential

I find it very frustrating when I am confronted by someone who is absolutely opposed to trying a topical vitamin A product, such as Retin A for their stubborn blackheads. There seems to be this prevalent misconception that the use of such as product MUST be irritating. That is simply untrue. I think the main problem is that too many times patients have been given Retin A (or similar product) in a form or strength inappropriate for their skin type and no instructions to help them diminish the likelihood of developing irritation. This also makes it difficult for me to convince a patient to retry the right product for them in the right way.

I have personally found my own set of directions very useful particularly for patients just starting out with a topical vitamin A product. This helps mitigate the irritation, dryness, redness, etc., that can develop early on and help keep patients motivated to continue using their products. This applies to stronger levels of retinol as well as prescription agents. As for the fear of using a topical Vitamin A product during the summertime. Applying such a product does not mean your skin will burn to a crisp if you go outdoors. It is certainly important that you wear a sunscreen daily (oil-free if you're acne prone) and pay attention to how much sun you're getting. But it doesn't mean just because it's summer you MUST give up your Retin A, etc. If you use a little common sense and a lot of sunscreen, you are unlikely to have problems. If you do have sunburn concerns, then consider a non-vitamin A product such as Kinerase for your skin rejuvenation during the summertime.

How To Apply Your Product

• Start out using your product EVERY OTHER NIGHT
• Wash your face (or other area of treatment)
• Wait 20-30 minutes
• Apply a PEA sized amount of cream to your finger
• Dab the cream/gel around the area to be treated and rub it in well
• Wash off your hands
• Keep your product out of your eyes
• If you are treating wrinkles around the eyes, you may apply the product under the eyes and to the crow's feet areas. Avoid applying products to the upper eyelids with the exception of Neova Eye Therapy or DERMAdoctor Wrinkle Revenge Rescue & Protect Eye Balm.

There are a few exceptions to the rule. Anyone using Retin A Micro Gel may have been told that the gel may be applied immediately after washing without harm. I have had too many patients still develop enough irritation to warn them just like a regular Retin A user. And while some patients may be able to increase the use of their product to every night, certain medications like Tazorac are better left every other night unless there is no clearing and they have no ongoing irritation.

Many people ask me about the acne flare that occurs after initially starting these products. The acne that is already microscopically forming beneath the skin is brought to the surface while it is normalizing the glands. This is temporary and should last only a few weeks should it occur. I would estimate acne flaring happens in less that a third of treated patients, so don't waste time worrying that it's going to happen to you. In general, acne will take between 6-8 to show significant improvement from therapy.

Vitamin A creams have been touted to help in the anti-aging process. This initially began with Retin A roughly 10 years ago. It was so popular that it sold out of pharmacies overnight. However, as people age, their skin becomes much drier and unable to tolerate a product like Retin A. Renova was developed in response to this need. Renova contains .05% tretinoin, the active ingredient in Retin A, but it is in a moisturizing base. I recommend it be used as discussed above for Retin A. This product helps erase fine wrinkle lines, smooth out the texture of the skin and helps reduce the appearance of blotchy skin discoloration. Tretinoin has also been shown to reduce some of the photoaging changes that can lead to precancerous growths known as actinic keratoses.

THE THREE R's: RETIN A, RENOVA AND RETINOL

Sometimes I get the feeling that nobody out there in the cosmetic industry understands the difference between these products, but I hope you will!

A Little History Lesson

Seems like everyone knows that Retin A helps with improving the appearance of fine lines, but I feel like an old woman when I say I remember the day the story hit the news (I was a dermatology resident) that Retin A, the acne medication helped treat wrinkles. Retin A promptly sold out across the nation that week. That event led to several things. The first was that there was this onslaught of patients presenting with terribly red, oozing, peeling skin because they were literally applying Retin A by the handful (remember Play By The Rules?) several times a day in order to look younger more rapidly. Needless to say, it doesn't work this way.

Second, medical insurance companies were introduced to prescription products suddenly used for "cosmetic" use, hence this was the true start of their refusal to pay for certain medications (think Retin A, Viagra, Rogaine, Propecia).

And finally, most women realized they had dry, sensitive skin at 40 and couldn't understand why they just couldn't tolerate Retin A. This ultimately led to the manufacturer taking the active, proven ingredient and finding a moisturizing base for them. Hence the birth of Renova, FDA approved for helping reduce the skin affects of the photoaging process. Renova is simply Retin A in a more moisturizing base aimed at aging women who typically have drier skin than we had as oily teenagers. If you read the PDR, you'll notice that Retin A is not FDA approved for this use but Renova is. Confusing, but they are one and the same, just different bases. And should you have oily skin and require a gel base instead of the heavy moisturizing base in Renova, (or want an even higher concentration of tretinoin), there is no reason you cannot be prescribed a different formulation of Retin A for these purposes. If you are unfortunate to find yourself with both acne AND wrinkles, I would recommend one of the Retin A formulations instead of Renova. Renova is heavy enough that it may cause a flare of acne in someone with pre-existing acne or someone prone to this condition.

This onslaught of the prescription vitamin A wrinkle therapy left the cosmetic industry in the cold, so ultimately the use of Retinol to fight wrinkles took off. Initially the strength of retinol used in the common cosmetic product was quite weak. Comparing Retinol strengths can help you determine their effectiveness. Afirm, which has at its lowest end Afirm 1X 0.15% retinol and increases in strength through Afirm 2X retinol 0.3% up to Afirm 3X retinol 0.6%. Neova makes Neova Retinol ME 0.15% with 0.15% retinol and Neova Retinol ME 0.30% with 0.30% retinol. DERMAdoctor Poetry In Lotion intensive retinol 1.0 contains the highest potency at 1.0%.

Often you will now see the ingredient retinyl palmitate in cosmetic products, too. Retinol is stronger than retinyl palmitate, and often they are both combined in a formulation.

Retinol can be equally as irritating as Renova, so I would definitely start out using it on an every other night basis just to make sure you can tolerate it. No matter what the level of retinol in a product, you do need to take the same careful approach to initially using this ingredient as you would with a Retin A, Renova, Avita, Differin or Tazorac. Too often retinol is mistaken as being gentle to the skin since it is so much "weaker" than Renova. However, I have often seen the same irritation and redness develop with the use of "mild" products such as MD Formulations Vit-A-Plus Anti-Aging Eye Complex. Don't let the concept of a product meant for sensitive skin lead you to making a mistake. MD Formulations Vit-A-Plus Anti-Aging Eye Complex is a lovely product, but you too can develop irritation if you don't start out using it wisely. Additionally, MD Formulations Vit-A-Plus Anti-Aging Eye Complex is not a moisturizer, so if you need additional hydration, layer Murad Eye Treatment Complex SPF 8 or Cellex-C G.L.A. Eye Balm on top.

Retinol is also as prone to increasing your sunburn potential as any prescription level topical vitamin A product, so do exercise caution when getting sun, and wear your sunscreen!

There is no question in my mind that the day Retin A became a "proven" wrinkle treatment that the true medical/cosmeceutical search for the fountain of youth started. And it all started with an acne cream!

If you find yourself using a topical vitamin A product every other night, particularly if you are experiencing any flaking, the use of a glycolic acid product such as MD Formulations Continuous Renewal Complex is very helpful for maximizing your skin rejuvenation results as well as controlling the flaking.

There seems to be some confusion regarding Kinerase and its relation to topical Vitamin A.

• Kinerase is NOT a topical vitamin A, but rather a plant growth hormone used for skin rejuvenation.
• Kinerase is NOT used for acne therapy.
• While you can alternate the use of Kinerase and Renova, you may want to select one and use a skin rejuvenation product that works in a different manner such as an antioxidant (Cellex-C, Neova or Prevage) or a glycolic acid like MD Formulations.

Vitamin A creams in general are not to be used during pregnancy or while nursing. The theory has been borrowed from the fact that large doses of oral vitamin A or derivatives such as Accutane can cause birth defects is taken during pregnancy. For safety's sake, these topicals should be avoided as well. While Retin A has been around more than 20 years, (and I have no doubt that many women used it accidentally during pregnancy), I know of no confirmed birth defects associated with its use. Still, it is better to be safe than sorry, so I recommend you avoid the use of topical vitamin A products if you know you are pregnant, trying to conceive or are nursing. If you find out you are pregnant while using a topical vitamin A product, don't panic. Simply stop its use and discuss it with your Ob-Gyn and prescribing dermatologist.

Topical Vitamin A is here to stay! Enjoy the many wonderful options and use them wisely and in good skin health!

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

www.dermadoctor.com
Copyright 2000-2010, DERMAdoctor, Inc., All rights reserved.

Click here for permission to use this copyrighted content.