Retinoids for the Cosmetic Patient

394 K.R. Beer

more youthful histologically as well as clinically. The role of the retinoids for cosmetic indications is expanding rapidly. Clinicians now routinely incorporate these products into their topical treatment regimens. They may be used with nonprescription cosmeceuticals such as glycolic acids, green tea, growth factors, vitamin C, and a host of other products. The optimal skin care regimen incorporating retinoids with these products has yet to be defined and most likely requires some trial and error based on the skin type of the individual being treated.

Retinoids also have a place as adjunctive therapy to “prime” the skin. Treatments using chemical peels, lasers, intense pulsed light, and perhaps even poly-l-lactic acid may be affected by the degree to which the epidermis and dermis have been pretreated with retinoids. Retinaldehyde

0.05% has been shown to improve outcomes of nonablative laser treatments. More studies of this type need to be performed to discover whether treatment with retinoids improves surgical outcome with various cosmetic procedures.

Quite simply, almost all cosmetic patients should be using retinoids. Patients who are irritated by the use of these products should use low concentrations of them or apply them twice per week until they are able to tolerate stronger or more frequent applications.

In my practice, the retinoid that I use the most is tretinoin. Typically, I begin my patients on the 0.025% cream. Whenever possible, I use the Retin A brand of tretinoin because I am comfortable with the vehicles used for the family of products and I am confident in the consistency of the product. Generic products may not always be from the same manufacturer, and this may result in varying concentrations and vehicles, which can affect patient compliance.

For patients who are Fitzpatrick type I or II, I instruct them to apply the cream every other night. They are instructed to apply the cream to dry skin, as applying it to moist or wet skin may increase the risk of irritation. After approximately 6–8 weeks, they are instructed to try to increase the application to nightly. If the skin becomes irritated, they are told to continue every other night usage for another 6–8 weeks before trying to increase the frequency again. Some patients simply will not tolerate daily usage of retinoids, and for these individuals, I use another product such as a green tea, vitamin C, or growth factor–containing product on their “off” nights. This enables me to be certain that the patient is using something nightly (which I believe increases compliance) as well as to provide the patient with the benefits derived from using another cosmeceutical. I will vary the cosmeceutical used based on the patient’s goals, skin type, budget, and experience in the past. Many patients use green tea products with retinoids, and there appears to be a synergistic effect.

Patients who tolerate the 0.025% cream for 3 months may progress to the 0.05 cream. As patients tolerate this, increase the concentration that they use. For most patients, the 0.05% cream is as high as they can tolerate, although some patients, particularly those with type III or IV skin, can go to the 0.1%. Several of my cosmetic patients who have used retinoids for decades have graduated to the 0.1%. Interestingly, they report very little irritation and minimal photosensitization.

Chapter 129 Retinoids for the Cosmetic Patient 395

Microsponge technology and an emollient base are variants of the basic tretinoin formula. Adding the emollient makes the product slightly less irritating, and it has a role for a select few patients. The microsponge technology delivers the active ingredient more efficiently. In practice, it is easier and less expensive to maximize the concentration of the traditional formula before migrating to the more expensive microsponge.

Tazoratene is packaged for cosmetic usage as Avage® . This product will restore the epidermis and dermis to a more youthful appearance clinically and histologically. It does not seem to have the patient acceptance of Retin A and may be slightly more irritating. I use this product intermittently and prescribe it much the same way as I do Retin A, beginning with the lower concentration and graduating to a stronger product after several months. One potential benefit of using Avage is that there is no generic substitute, so that if you prescribe this drug the patient will get it.

As previously mentioned, I believe that many cosmetic patients will benefit from pretreatment with retinoids. Patients undergoing nonablative laser, intense pulsed light, and perhaps injections of poly-l-lactic acid should benefit from treatment with retinoids. For patients undergoing nonablative laser or intense pulsed light, treatment with the 0.025% concentration should be utilized for at least 6 or 8 weeks to maximize outcomes. In theory, the inhibition of metalloproteinases caused by treatment with tretinoin should increase the collagen formation with injection of poly-l-lactic acid. To date, there are no studies to demonstrate that this is the case, but from a theoretical perspective, treatment with tretinoin for 6–8 weeks prior to injections as well as throughout the course of the treatment makes sense.

In conclusion, most cosmetic patients can benefit from the use of retinoids. They are great adjuncts for rejuvenation and potentially may increase the utility of various cosmetic procedures performed. Retin A has the longest record of safety and efficacy in this category, but other products are available, and more are on the horizon.

Suggested Reading

Gilchrest BA. Treatment of photodamage with topical tretinoin: an overview. JAAD 1997;36:S27–S36.

Griffiths CEM, Russman AN, Majmudar G, Singer RS, Hamilton TA, Voorhees JJ. Restoration of collagen formation in photodamaged human skin by tretinoin (retinoic acid). N Engl J Med 1993;329:530–535.

Kang S, Leyden JJ, Lowe NJ. Tazarotene cream for the treatment of facial photodamage. Arch Dermatol 2001;137:1597–1604

Kligman AM, Grove GL, Hirose R, Leyden JJ. Topical Tretinoin for photodamaged skin. J Am Acad Dermatol 1986;15:836–839.

Kligman Am, Leyden JJ. Treatment of photoaged skin with topical tretinoin. Skin Pharmacol 1993;61(suppl):78–82. (Review).

Mordon S, Lagarde JM, Vienne MP, Nocera T, Verriere F, Dahan S. Ultrasound imaging demonstration of the improvement of nonablative laser remodeling by concomitant daily application of 0.05% retinaldehyde. J Cosmet Laser Ther 2004;6:5–9.

Rokhsar C, Lee S and Fitzpatrick R.Review of photorejuvenation: devices, cosmeceuticals or both? Dermatol Surg 2005;31:1166–1178.

398 B.R. Moody

Figure 130.1. typical actinic keratoses manifest as rough scaly papules.

402 A.J. Kaufman

smoke, or have unrealistic expectations. Avoid a medium-depth peel over surgically undermined areas (e.g., rhytidectomy) for 6 months.

3.Purchase chemical peel supplies from medical supply organizations rather than your local pharmacy to avoid any problems or discrepancy in the concentration of the acids used. (Concentrations are weight-to-volume.)

4.Medium-depth chemical peels are usually accomplished using a combination of Jessner’s solution or glycolic acid followed by 35% trichloroacetic acid (TCA). Concentrations of TCA greater than 40% have an unpredictable risk of delayed wound healing or scarring. Cleanse and degrease the skin with acetone before applying a single coat of Jessner’s solution with gauze pads. After the Jessner’s solution is dried, 35% TCA is applied with cotton-tip applicators or gauze pads to give an even, light frost. When using glycolic acid, apply 50–70% glycolic acid and leave it on for 2 minutes. If the patient complains of significant burning, shorten the application time and neutralize the glycolic acid with tap water. After neutralization for 2 minutes or less the area is toweled dry and 35% TCA is applied for an even frost. For deeper rhytides or areas with greater sun damage, apply additional TCA to get a deeper, whiter frost. Cool, wet compresses and a hand-held fan are used to comfort the patient after the TCA has dried and frost appeared.

5.Many patients tolerate the procedure without any anesthesia, but most patients receive Vicodin and Valium 30 minutes preoperatively.

6.Edema of the treated area is common for the first 48 hours and is minimized by head elevation and nonsteroidals. Wound care consists of skin hydration via liberal application of water to the treated areas. Acetic acid compresses (one tablespoon to one pint luke-warm water) twice daily decreases the risk of infection. Once peeling begins, a bland ointment, such as Aquaphor, is applied several times daily to keep the area moist and speed reepithelialization. Once healed, the patient starts a noncomedogenic sunscreen and sun-protective measures and may restart tretinoin and hydroquinone.

7.Patients are seen frequently in the postoperative period and are instructed to return for any symptoms suggestive of an infection, delayed wound healing, scarring, or pigmentary problem. An early sign of herpes simplex infection is increasing pain beginning a few days after a peel. One of the earliest signs of a scar is persistent erythema and pruritus. It is much easier to treat complications of chemical peeling at an early stage.

8.I frequently use medium and superficial chemical peels. A series of super cial peels (e.g., glycolic, salicylic, Jessner’s, or low-concentration TCA) is well suited for younger patients with fine lines and dyschromia.

Medium-depth peels work best for older patients with more extensive actinic damage. For severe actinic damage and deep rhytides I prefer to use a laser rather than deep phenol peels. While one can cause permanent hypopigmenation with a carbon dioxide lasers, I feel that I have better control over the depth of injury using a the Erbium:YAG laser.

Chapter 131 Chemical Peels for Facial Rejuvenation 403

9. One nal pearl is to start out with superficial peels and ideal patients

(blond hair, blue eyes, light complexion). Develop a sense of comfort and build upon your experience before performing deeper peels or dealing with patients at greater risk of pigmentary alteration.