Is Retin-A the fountain of youth? Well, you can’t really drink the thick cream, but as far as skin rejuvenation in concerned, it’s as close to the fountain of youth as you can get in the year 2014!

What’s the “real deal” with Retin-A? An excellent article recently appeared in Plastic and Reconstructive Surgery on this topic (PRS 2014; 4: 481e-490e).

Retin-A is a derivative of Vitamin A. Remember when your mother told you to eat carrots if you wanted good eyesight? Carrots are an excellent source of beta carotene and give carrots their orange color. That’s why people who eat lots of carrots tend to look a bit orange! In the body, beta carotene is converted to Vitamin A, an antioxidant. Vitamin A is important for proper functioning of the eye. So your mother was right!

Retin-A belongs to a class of compounds called retinoids that are derived from Vitamin A. Other examples of retinoids include Accutane, which is used in the treatment of severe acne. Retin-A in a cream form has been used for over 30 years as a treatment for sun-damaged skin.

What do we see in sun-damaged skin and how does Retin-A correct it? First, a brief anatomy lesson on skin. Skin is composed of an outer layer called the epidermis and an inner layer called the dermis. Just beneath the dermis is the outer fat layer known as subcutaneous fat.

 

  • The epidermis has lots of skin cells. The more numerous ones are termed keratinocytes and are responsible for keeping water in and sunlight out! There are also pigment-producing cells called melanocytes. The deadly cancer involving these cells is called melanoma.
  •  The dermis has more collagen than cells. It also contains a gel-like substance called hyaluronic acid, the active ingredient of Juvederm that is injected into the face for the filling of wrinkles. In addition there is elastin that is responsible for our skin’s elasticity.

How does Retin-A work to correct sun-damaged skin?

• It thickens the epidermis, giving the skin a thicker look and feel, making it less fragile. This increase in dermal thickness also allows the skin to hold on to water, making it less dry and leathery.

• It compacts the outer layer of dead skin cells, decreasing skin roughness.

• Retin-A increases the amount of hyaluronic acid in the epidermis and the dermis, much as if you were injecting Juvederm! This results in better skin hydration as well as fewer wrinkles!

• It improves the blood flow to the skin, giving it more pinkness that counters the yellowish appearance of sun-damaged skin.

• It increases the amount of collagen in the dermis, decreasing skin wrinkles and giving the skin more thickness.

• Sun-damaged skin has a great deal of abnormal elastin that apparently results from degradation of the large amounts of normal elastin by the process of inflammation. Retin-A decreases the amount of this abnormal elastin.

“Wow!” you say. “That’s impressive!! How can I get started?” Retin-A is available by prescription only, so you’ll need to see a doctor. The most commonly prescribed strength is .05%, and most physicians recommend that the patient wash and dry their face and apply the cream at bedtime. I suggest that a patient start out gradually, applying it every third night, then every other, and finally every night. Be sure to use a sunscreen during the day since the compacting of the outer dead cell layer decreases the ability of the skin to block ultraviolet rays from the sun.

How quickly does Retin-A act?

Epidermal thickening and improvement in fine wrinkles may be seen as soon as 3 months.

• After 6 months of treatment, dermal changes occur that is evident as an improvement in both fine and coarse wrinkling, replacement of the yellowish color with a normal color, decrease in the blotchiness of the skin, decreased roughness, and increased skin tightness.

• After 12 months there are further dermal changes with new collagen formation as well as a decrease in the large amounts of abnormal elastin in the dermis.

What to expect? At first there is usually redness, scaling, dryness, and itching, which is known as the “retinoid reaction.” By applying the Retin-A every 3rd night and gradually working up to every night, these side effects are minimized and do disappear with time. Some patients may not tolerate the .05% strength but may be able to tolerate a weaker strength. Some physicians also start patients out on a much stronger concentration of Retin-A. They have found that the “retinoid reaction” disappears within 2 weeks and that the improvement in the skin after only 6 weeks was as great as that after one year of using the .05% cream.

For how long should one use Retin-A? Because some of the beneficial effects may disappear after discontinuation of the drug, the recommendation is that one continues to use it indefinitely, although many doctors are fine with decreasing the frequency with which it is applied to perhaps twice a week.

Serial photos taken of a patient who has used Retin-A for 5 years. These are courtesy of the PRS article mentioned above.

Finally, how safe is Retin-A? Pregnant patients are advised to avoid it, although no concrete evidence of an increase in birth defects. I am delighted to report that there are no systemic side effects that have been reported in 3 decades of usage.

Feel free to comment.

George Sanders, M.D.