Retinoids explained: retinol, tretinoin and how to start

Key takeaways

• Retinoids act on genes in skin cells that control turnover. They help acne, dark marks after pimples, sun damage and fine lines.
• Retinol and retinaldehyde are in cosmetics. Tretinoin, adapalene, tazarotene and trifarotene are prescription retinoids. Tretinoin tends to irritate most, adapalene least.
• Redness, dryness and peeling in the first weeks are common. Starting slowly prevents most of it.
• Retinoids increase sun sensitivity, so daily sunscreen is not optional. Some retinoids must not be used in pregnancy.
• Improvement usually takes twelve weeks or longer. For ageing, the benefit builds over six months or more.

What do retinoids actually do?

See, what happens is, retinoids bind to receptors inside skin cells and switch on genes that control how quickly the cells mature and shed. DermNet explains they also reduce the transfer of pigment into skin cells and help disperse melanin. In practice, that means three things: - Pores are less likely to plug, so fewer blackheads and pimples. - Pigment, such as marks after pimples, fades faster. DermNet notes this is particularly useful in skin of colour. - Over months, the skin builds more collagen and looks smoother. Long-term tretinoin, over six months, may reduce fine wrinkles and sun spots.

That combination is why I use retinoids so often in Indian skin. Acne and the dark marks after it are one problem for most of my patients, and retinoids work on both.

Retinol, adapalene, tretinoin: what is the difference?

Normally I start acne-prone skin on adapalene, and ageing concerns on retinol or a low-strength tretinoin, depending on how robust the skin is. Prescription retinoids are a decision I make after seeing your skin, not something to pick from a shop shelf because a friend uses it.

How do I start a retinoid without peeling?

This is the part people get wrong. They apply a lot every night from day one, the face peels and burns, and they stop. Here is how I teach it:

1. Night only. DermNet advises once daily at bedtime.
2. Pea-sized amount for the whole face. Dot it on the forehead, cheeks and chin, then spread.
3. Dry skin first. Wait ten minutes after washing so the skin is fully dry.
4. Two or three nights a week for the first two to four weeks. Then every other night, then nightly if comfortable.
5. Moisturiser. Apply it after the retinoid, or before it if you are sensitive (the "buffer" method).
6. Avoid the corners. Keep away from the corners of the nose, mouth and eyes, where it irritates most.
7. Sunscreen every morning. DermNet lists sun sensitivity as a side effect.

Creams tend to be less irritating than gels. Gels feel lighter on oily Mumbai skin. Choose by your skin, not by price.

What about "purging", redness and dark patches?

In the first four to six weeks, some people get more small pimples. This is often called purging: the retinoid brings existing blocked pores to the surface faster. It usually settles. If you get new pimples in places you never break out, or burning that does not settle, that is irritation, not purging. Reduce how often you apply it.

In brown skin, irritation itself can leave dark patches. That is very important to understand. A retinoid used too aggressively can cause the very pigmentation you are trying to treat. Slow is faster in the end.

Also avoid mixing a new retinoid with strong acids, scrubs, or waxing the area. Stop it for a few days before a peel, laser or facial waxing unless your doctor says otherwise.

Is it safe in pregnancy?

DermNet notes that some topical retinoids are contraindicated in pregnancy and that tazarotene carries a pregnancy risk. Oral retinoids such as isotretinoin are well known to harm a developing baby. My advice is simple: if you are pregnant, trying for a baby or breastfeeding, stop retinoids and tell me, and we will choose alternatives such as azelaic acid. More in skin changes in pregnancy.

Who should be careful with retinoids?

• People with eczema or very sensitive skin. Retinoids can make eczema worse. Calm the skin first, see sensitive skin.
• People with rosacea. Some tolerate a very low strength; many do not.
• People who spend long hours in the sun for work and cannot reapply sunscreen.
• Anyone using a steroid combination cream on the face. Stop that first, with a doctor's help.

How long until I see results?

DermNet says improvement may take twelve weeks or longer. For acne, I expect a change in about two to three months. For dark marks, three to six months, with sunscreen. For fine lines and texture, six months and more, and the benefit continues with long-term use. Basically, a retinoid is a long game. It suits people who like steady results more than quick ones. For a full anti-ageing view, see our anti-ageing plan.

How we approach this at Dr Tvacha

At a Rs 499 skin consultation I decide whether a retinoid suits your skin, which one, at what strength, and how to start it, and I write the schedule down. If you also need treatment for acne, marks or scars, that is planned and quoted in writing before you pay. Our approach, Diagnose, Treat, Protect, Maintain, is on the Second Layer Skin Plan page. You can also read the only skincare routine most people need to see where a retinoid fits.

Written by

Dr Amit KarkhanisAesthetic Physician · MBBS, Dip. Dermatology (UK) · Reg. No. 2001/02/1124

Founder of Dr Tvacha, practising in Thane since 2005. Leads the weight loss and hair programmes.