The topic comes up occasionally, but I haven't seen an extensive discussion devoted to the use of Retin-A (tretinoin) in the treatment of Rosacea. I've had some success using tretinoin for my Rosacea, and I thought it might be helpful to talk about it. I don't think it gets enough love.
I hope the moderators will not mind me sharing my thoughts (and opening the discussion). I'm assuming that most people here know about Retin-A, & are at least a little familiar with its use for acne & aging skin, and the irritation it's notorious for causing - which might make it seem a little controversial for Rosacea skin.
I don't claim expertise on this subject I'm not a dermatologist, nor medical researcher. I don't have answers to all the questions; since the experts out there in the field are still learning about what retinoids do, I surely wouldn't say I know very much. But I was already skincare-obsessive when I learned I had Rosacea, and I researched to the point where I was willing to put my own face to the test; I felt confident I was making the right choice when I asked my doctor to prescribe 0.025% tretinoin cream (generic Retin-A) as part of my Rosacea treatment. I am very glad I did, because it does help my skin behave more 'normally'. I did have previous experience with Retin-A, so I was not flying blind.
I lost all the links I had from when I was doing my research all those months ago. But Google searches on 'tretinoin rosacea', 'tretinoin angiogenesis', and so forth will bring up lots of info (some contradictory, of course). The internet is just a labyrinth of information and opposing viewpoints ...
A brief, serviceable overview from the Cosmetic Ingredients Dictionary at Paula Begoun's Cosmetics Cop site:
Retin-A. One of several prescription-only drugs (others include Renova, Micro, and Avita) that contain tretinoin (technical name: all-trans retinoic acid), which is the acid form of vitamin A, as the active ingredient. In skin, tretinoin is the form of vitamin A that can actually affect cell production by binding to the tretinoin receptor sites on the cell. There is a great deal of research establishing that tretinoin is effective in improving cell production in skin that has been damaged (often by exposure to sunlight). Tretinoin is a valid method for addressing wrinkles and, overall, for improving cell production. Applying tretinoin does not produce miraculous results, but the positive outcome in terms of skin health is indisputable. However, it is highly possible that applying tretinoin to the skin will cause irritation, which is a major drawback of this drug. See*tretinoin.
retinol. The name for the entire vitamin A molecule. Retinol has value for skin on several fronts: it is a cell-communicating ingredient and antioxidant. Skin cells have a receptor site that is very accepting of retinoic acid, which is a component of retinol. This relationship between retinoic acid and skin cells allows a type of communication in which the cell is told to function normally (that is, not like a damaged or older cell), and it can, to some extent, conform to that request. Retinol cannot communicate with a cell until it has been broken down into retinoic acid. Some of the controversies regarding using retinol in skin-care products have been its stability in skin or in a skin-care product, whether it can be converted into retinoic acid after it is absorbed into the skin, and how much retinol is needed so that as it is changed to retinoic acid there is still enough that can get to the cell. However, over the past couple of years, some new, stable forms of retinol have become available, along with lots of impressive research regarding their efficacy. Retinol helps skin cells create better, healthier skin cells and increase the amount of skin-support substances. Packaging is still a key issue, so any container that lets in air (like jar packaging) or sunlight (clear containers) just won't cut it, something that applies to most state-of-the-art skin-care ingredients. Lots of retinol products come in unacceptable packaging.
tretinoin. Topical, prescription-only medication that can improve skin cell production after skin has been damaged. It is the active ingredient in Retin-A, Renova, Tazorac, and Avita. One of the more significant problems of sun damage is abnormal and mutated cell growth. An article in Clinics in Geriatric Medicine*(November 2001, pages 643659) stated that Studies that have elucidated photoaging pathophysiology have produced significant evidence that topical tretinoin (all-trans retinoic acid), the only agent approved so far for the treatment of photoaging, also works to prevent it (Sources: Cosmetic Dermatology, December 2001, page 38; and Journal of Investigative Dermatology, 2001, volume 111, pages 778784). Tretinoin affects and improves actual cell production deep in the dermis, far away from the surface of skin (Sources: Clinical and Experimental Dermatology, October 2001, pages 613618; Clinics in Geriatric Medicine, November 2001, pages 643659; and Photochemistry and Photobiology, February 1999, pages 154157).
Basically, a retinoid is a cell-communicating ingredient that binds to the retinoid-receptors in the skin & tells the cells to 'act normally'. It is not necessary for it to irritate or peel the skin excessively to communicate that message, though many retinoids are notable for doing just that (irritating the skin) - there is an exfoliating effect that takes place when the retinoid acts on the receptors & the cells speed up their cycle of development in the process of beginning to 'act normally'. That's my 'for dummies' version (I'm the dummy ).
It is not peeling, redness, or irritation that does the work of Retin-A (that misinformation was spread for years I remember doctors saying it was the irritation & peeling that was clearing acne through exfoliation, which is why they gave poor acne-suffering teenagers the strongest form - 0.1% in an alcohol-based gel form, sure to dry, irritate, redden, and HURT less hardy skin), though a lot of people still think so. Irritation is a side effect, not the action.
It is the message being delivered to the cells that matters the message to behave like healthier (& younger, in the case of anti-aging treatment) cells. Higher strengths are not more effective than lower strengths, in terms of communicating that message higher strengths are just an opportunity to create more irritation. It's absolutely unnecessary to promote irritation to get results, especially with sensitive Rosacea skin.
Some of the possible benefits of tretinoin for Rosacea: thickening of the dermis (the better to hide capillaries with, my dear?), possibly anti-angiogenic, cell normalizing, anti-inflammatory.
I see Rosacea sufferers being advised to avoid retinoids because of those notorious irritating effects but I think tretinoin is a valuable addition to the toolkit for some of us, and worth considering if you have enough information, and are willing to be patient when adding it into your regime. I don't think doctors who suggest it as part of Rosacea treatment do so out of ignorance (as is sometimes implied) quite the opposite. But I do think patients need to be better informed about what it is & how to use it properly and a dermatologist who says nothing more than to 'use it nightly' IS ignorant! You MUST introduce retinoids slowly to avoid serious irritation. A little irritation is to be expected, some redness, some peeling, from those exfoliating effects but it should be no more than a manageable & temporary annoyance. Topicals like Finacea are also known to cause initial irritation; short-term irritation does not equate to a lack of long-term benefit.
Rosacea skin, especially, must take it very, very slowly. For me, it was well worth it to manage those first few weeks of adjustment. I would love to see a Rosacea-specific tretinoin formulation!
Some skins are truly intolerant of retinoids in any form. But I think for many, 'intolerance' is the result of using too high a strength, and/or too often.
I am an example of that. I experienced the first signs of my Rosacea several years ago - during a period of HIGH stress - and assuming it was all acne, I went to the derm's acne clinic. What I had were lots of papules on my cheeks, and nodules along the chin/jaw. The nurse-practitioner prescribed some standard adult acne topicals (BP, clindamycin), including 0.025% tretinoin cream. The other prescriptions didn't do anything for me but upset my skin more (I stopped using them) - but the tretinoin alone cleared my skin to a point of near perfection. After many months of tolerating this easily & well, I was 'moved up' to 0.5% tretinoin (because they ALWAYS move you up in strength) - which my skin NEVER adjusted to. My face went red & stayed red long after I stopped using it. I had a permanently pink face for several years, and continued battling weird breakouts (and irritation, and dryness, and you know what I'm talking about) - until flushing finally clued me in to Rosacea. But I have come back to 0.025% strength tretinoin, with very good results.
What tretinoin does for me: at the more obvious level, it reduces inflammation & papules; less obviously, it normalizes the overall behavior of my skin, which is somewhat harder to quantify but I saw it happen over a period of months with smoother skin & faster healing. Tretinoin literally deflates & erases those 'spots' and inflammatory plaques I get when I flare, often overnight. Hopefully that makes sense. I use it every other night; if I've hit one of my triggers & flare up badly, I'll apply it on the 'off' night only as a spot treatment to individual paps/plaque areas, and I'll see huge improvement by the next morning. I still have Rosacea - I flare from triggers that I am still sorting out - but tretinoin is a very reliable topical treatment for me. If I had to choose between MetroGel & tretinoin - I would choose tretinoin! I think it does much more for my skin - at times I have been out of Metro for weeks, and done just fine with tretinoin and my OTC skincare. Metro manages overall inflammation quite nicely, but tretinoin tells my skin cells to actually behave like healthier cells. Aside from flares (from food, weather, and skincare triggers), my skin appears overall less pink now than it did a year ago, and I attribute that to the effects of tretinoin slowly but surely improving my skin, layer by layer. I also like that I'm using the most proven anti-aging topical there is, without risking additional reactions.
- When starting out with tretinoin, begin very slowly to allow your skin to adjust to it. It does have that notorious exfoliating effect that can cause irritation. But much of this is worsened by overloading the skin with it - the effects accumulate. When the directions say 'use a pea sized amount' - they really mean it, and that's for tougher skin than ours. Applying tretinoin as you would an over the counter moisturizer is a recipe for disaster! More is NOT better.
- By slowly, I mean SLOWLY. Please do not begin by applying tretinoin nightly! Begin by applying it every third night for the first few weeks (1 night on, 2 nights off) - or even the first couple of months. If you tolerate it well, move up to every other night. If you tolerate that well, it's perfectly acceptable to stay on that schedule, if you are seeing benefits. You are not required to use it nightly if every other night is working well for you. If you are tolerating it well, every night may be fine. But every other night may be the perfect schedule for you, so don't feel compelled to increase the frequency. I have read that skipping more than 3 days undermines your skin's adaptation (there needs to be regular supply of retinoid or you're starting again from scratch - and apparently 3 days is the longest it stays active on the skin), so bear that in mind.
- Do not apply this as you would for acne (the directions are always for acne) - use even less, or dilute it. Suggestions: moisturize with a bland moisturizer FIRST, allow it to absorb for 5 to 10 minutes, then apply tretinoin AFTER; or mix your half a pea to pea of tretinoin with your usual amount of moisturizer, and apply the diluted tretinoin-moisturizer mix to your face. You can even start the process by applying a tiny pinpoint's worth of tretinoin to individual papules & pustules for the first few applications. It is possible you will experience that 'initial breakout' so many acne sufferers experience with retinoids - I think it happens less often with the slower approach, and it's more likely with those who are acne-prone to begin with.
(I did get redness & peeling at first in papule-riddled areas where I applied tretinoin nightly rather than every third night (I was impatient!) - and the areas I was most prone to acne breakouts did see a little bit of that for about three weeks. The areas where I had been patient about applying every third night did not get overly-irritated nor red, as I recall.)
- Use a low strength - .025% is sufficient. The research papers I've found out there on the web indicate 0.025% (standard tretinoin, I don't know enough about Retin-A Micro, which offers different strengths) is the maximum effective strength for anti-aging & 'cell communicating' effects. It is supposedly well-tolerated by most skin types. Higher strengths are not more effective - they are only more irritating. Personally, I like the cream forms I've used - I have dry skin. Oilier/combination skins might prefer a gel form.
- Remember that retinoids make your skin more sun-sensitive! If you have a good sunscreen, use it without fail! If you are like me, and haven't found one yet that you can tolerate ... be very, very, very careful about protecting your face from the sun.
I only have experience with tretinoin. I don't know about other retinoids or even Retin-A Micro - there is a LOT of information out there, and I'm sure someone, somewhere is talking about those other retinoids & Rosacea.
Other thoughts and experiences to share??