Clinical Review: Topical Retinoids

Sheri L. Rolewski


Dermatology Nursing. 2003;15(5) 

In This Article

Patient Education: Expectations and Precautions

Retinoids deliver a plethora of benefits to individuals of various ages. In addition to the FDA-approved indications, topical retinoids have numerous off-label benefits and a promising future. Topical retinoids can be tailored to simultaneously address various specific dermatologic needs of patients. The benefits of topical retinoids often outweigh the risks.

It is important to educate patients about the possible risks, benefits, and reasonable expectations of retinoid therapy, and address common concerns before they fill their prescription(s). Stress the differences they will find in the package insert compared to the directions you are advising. Address the common use of off-label medications and remember to sight current literature and case findings to support your rationale. If you are suggesting the use of a medication for off-label use, be sure that the patient is aware of this and willing to follow your recommendations. An evidence-based approach to medicine, consisting of clinical research, case studies, and clinical experience can provide comfort in prescribing medications for off-label use. It also helps to practice what you preach and reassure the patient that you have personally used off-label medications, and empathize with what he/she is likely to encounter. Encourage questions and offer guidance throughout this process. Many subsequent "panic calls" can be avoided by providing sensible education up front. Supplemental patient educational handouts are also helpful, to reinforce your instructions and expectations. Patients are often overwhelmed with new regimens and advice, and can absorb a limited amount of information during their visit. It's beneficial for them to review what you've addressed, at their convenience, when they're ready to adapt to their new routine.

To enhance compliance, it is important for the patient to expect a temporary irritation phase. This temporary irritation usually lasts about 6 weeks, depending on the amount of damaged skin present. A person who has extensive sun damage may peel beyond the usual 6 weeks. The peeling represents a repair of sun damage. Tingling or slight stinging upon application, temporary increased erythema, and intermittent peeling of skin is common. Acne can actually flare initially, because retinoids tend to reveal what's hiding under the surface. Reinforce that with prolonged use, acne and enlarged sebaceous glands can be minimized. To help minimize the peeling during the day, advise patients to use the tips of their fingers in circular motions, particularly in areas of movements such as around the eyes and mouth. This works well in the shower. Advise patients to avoid picking, vigorous rubbing of the skin, or using abrasive body scrubbers or washcloths. The damaged skin will come off when ready. Pat the skin dry, rather than rubbing.

If burning, discomfort, itching, or excessive bothersome peeling occurs, recommend taking 1 to 2 nights off of the retinoid. Moisturize during the break and then resume the retinoid with only a broad-spectrum sunscreen (with a physical block such as zinc oxide or titanium dioxide as the key ingredient) serving as the moisturizer. Patients should avoid missing more than 2 days of the retinoid, to minimize the duration of the irritation phase. This irritation phase can be prolonged if using additional moisturizers (other than a sunscreen) or if more than 2 nights are missed. Decreasing the frequency of application when treating areas such as the eyelids, neck, torso, or extremities to 2 to 3 times a week may be desired. Sensitivity and pruritus can occur quickly. If patients find the prescribed regimen to be intolerable, encourage them to be patient and review the numerous benefits. Decreasing the frequency to every other day or even 3 times a week can be helpful. The strength can also be temporarily decreased until they can tolerate the addition of a retinoid. A gradual increase in the strength and frequency can then be achieved.

Preventative, healthy practices must be encouraged. Health care providers should stress the importance of becoming "sun smart." Sunscreens are considered the gold standard for protecting the skin from the harmful effects of UV light (Leyden, 2003). A physical UVA/UVB block from the sun, such as zinc oxide or titanium dioxide, provides the most protection. Encourage patients to become label readers and look for one of these key ingredients when selecting a sunscreen. Remember that damaging rays from the sun can penetrate the clouds and even glass. This underscores the importance of applying daily sunscreens on cloudy days, and even winter months. Those people working by a window or riding in a vehicle are also at risk. When feasible, peak hours of the sun should be avoided (10 am to 4 pm). Patients should seek shade, when they can. Once-a-day sunscreen application is often not enough. Appropriate use should be reviewed. Exposed areas of the skin should be protected with an appropriate sunscreen 30 minutes prior to exposure, and a second application administered, to ensure adequate coverage. When exposed to the elements, sunscreen application is recommended to be applied every 2 hours, and more often if sweating or swimming. A sun-protection lip balm is also beneficial. If prolonged sun exposure is expected, such as during a vacation, discontinue use of the retinoid 1 week before the exposure and resume upon return. With prolonged use, tretinoin protects the skin against harmful UVB and UVA rays (Bhawan et al., 1996).

At most, topical retinoids, including tretinoin, adapalene, and tazarotene, deliver minuscule amounts of active ingredient into the circulation. Definitive links to systemic toxicity in humans are practically nonexistent. Though causation was not proven, birth defects have occurred in two patients treated with tretinoin and one patient treated with adapalene (Akhavan & Bershad, 2003). Avoiding these topical agents in pregnant women is advised. It is imperative to educate patients regarding the risks, benefits, and reasonable expectations of topical retinoids. If trying to become pregnant or if pregnancy occurs, patients should discontinue topical retinoids. The safety of topical retinoids during lactation is not known. It has been recommended to begin therapy during a normal menstrual period (Physicians' Desk Reference, 2001) (see Table 4 ).

If facial waxing is desired, advise patients to discontinue total use of the retinoid for 5 to 7 days prior to waxing and resume the day after. This will prevent a brush-burn effect.

Over-the-counter blackhead remover strips are effective; however, advise caution when using in conjunction with a retinoid. To avoid preventable irritation, decrease the duration of application of the pore strip to the minimal duration recommended in the package insert.

If using adjunctive topical therapies, it is often recommended to use some products in the morning only and reserve the retinoid for bedtime. The concurrent combination of some common products can be extremely irritating, drying, and may counteract the retinoid. Allow effects of benzoyl peroxide, sulfur, resorcinol, salicylic acid, and/or other topical agents to subside before applying a retinoid. It is also recommended to avoid keratolytics, abrasives, astringents, drying agents, high-alcohol containing products, spices, and lime with the use of tretinoin (NPPR, 2003).


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