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Tretinoin improves the histological process of photoaging but cannot completely repair sun-damaged skin or eliminate all wrinkles {01} {02}. Furthermore, topical tretinoin has caused delayed ossification in a number of bones in the offspring of rats and rabbits given 100 to 320 times the usual topical human dose, respectively. If there is no response, the concentration of the tretinoin preparation and/or frequency of application should be increased. Lightening occurs because tretinoin reduces the melanin content in the epidermis, compacts the stratum corneum {17} {19} {20} {21} {46}, and thickens the epidermis {25}; it is not a result of a change of number or size of melanocytes {20}. Patients who have been compliant but unsuccessful when using skin care and sun avoidance programs alone may benefit by adding tretinoin to the regimen. {01} {21} {26} {47} {49} Tretinoin diffuses across cell membranes and complexes with specific cytoplasmic receptors, which can then enter the cell's nucleus and bind to DNA. {13} {15} Tretinoin has also been reported to suppress keratin synthesis {13} {16} {26} {29}. Although not clearly associated, 30 cases of congenital malformations have been reported for topical tretinoin during 2 decades of clinical use. Safety and efficacy have not been established for tretinoin's use in treatment of photoaging for adults 50 years of age and older. I was really hesitant to go on any tretinoin cream because of the dreaded 'it gets worse before it gets better'. {12} {16} Treated areas of skin should not be washed for at least 1 hour after applying tretinoin. Tretinoin should be applied to dry skin (20 to 30 minutes should be allowed after washing) to reduce possible skin irritation that worsens or occurs more often if tretinoin is applied any earlier to nondry skin. Tretinoin may be used with systemic antibiotics for treatment of all grades of acne, including severe (Grade IV) acne conglobata {04}; however, tretinoin is not effective when used alone for severe acne conglobata {08} {12} {14} {16}. Although use of tretinoin alone is effective in the topical treatment of mild acne vulgaris (Grades I to III), the therapeutic effect may be increased when tretinoin is used in combination with topical antibiotics {15} or benzoyl peroxide when acne consists predominately of comedones, papules, and pustules {12} {13} {16}. If irritation becomes severe, tretinoin should be discontinued until irritation substantially lessens or heals. {52} Topical tretinoin has been shown to be fetotoxic in rabbits given 100 times the usual topical human dose {01}. Tretinoin may improve but not clearly resolve hyperpigmented skin {20}. , cytoplasmic tretinoin receptor) cannot activate the gene transcription factors or the hormone-response element. 05% tretinoin cream was applied for 24 weeks, patients averaged a 27. Tretinoin should not be applied to mucous membranes; contact near the eyes, lips, or nose should be avoided {01} {26}. Tretinoin does not appreciably absorb ultraviolet light, cannot be regarded as a sunscreen, and will not protect the skin from redness {09}. {26} {49} Topical acne products, such as antibiotics or benzoyl peroxide, are used therapeutically with tretinoin to treat acne but can increase the risk of skin irritation. Treatment of acne vulgaris with topically applied erythromycin and tretinoin. In addition, tretinoin is thought to increase the growth and differentiation of various epithelial cells, increase the glycosaminoglycan-like substance in the compacted stratum corneum, increase the number of anchoring fibrils, and improve epidermal dysplastic changes {23}. It is recommended that topical tretinoin not be used during pregnancy. Although the clinical significance is not known, some patients using the water-in-oil formulation of tretinoin cream 0.
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