Some of us remember the 1980’s Wendy’s advertisements where the customer looks at her fast food burger and asks “Where’s the beef?”  Well, that’s my question when it comes to topical products for skin restoration.  Does the product have ingredients with proven efficacy and safety to justify the cost?

Maintaining one’s best appearance starts with preventing sun-related problems.  For a discussion about preventing sun-related skin problems, please refer to my blog on sun protection.  My curent core list of proven effective compounds for skin restoration includes topical retinoids, hydroquinone, azelaic acid, alpha hydroxy acids and vitamin C.  Hydroquinone, azelaic acid, alpha hydroxy acids and vitamin C are the topic of Topical Treatments for Skin Restoration Part 2.  In my opinion, if tolerated, topical retinoids should be the foundation of any skincare program intended to restore skin quality.  They have been shown to help restore collagen and elastic tissue and to reduce fine lines and tan spots.  Additionally, they provide synergy when used in conjunction with other topical skin care products such as skin lighteners.   It should be emphasized that oral retinoids result in severe birth defects if taken during pregnancy.  Variable quantities of topical retinoids are absorbed through the skin into the bloodstream.  Consequently, women contemplating pregnancy, or who are pregnant, should not use topical retinoids.

Topical Retinoids

Topical retinoids include over the counter retinol (vitamin A), retinaldehyde, Differin (adapalene 0.1% gel) and prescription tretinoin and tazarotene.

Currently, I am aware of only three FDA approved prescription topical retinoids for skin restoration:

  1. Renova (0.02% tretinoin), approximately $290.22/40 gm, for the “palliation of fine wrinkles.”
  2. Refissa (0.05% tretinoin), approximately $106.91/20 gm, for the “palliation of fine wrinkles, mottled hyperpigmentation and tactile roughness of facial skin”
  3. Avage (0.1% tazarotene), approximately $387.73/30 gm, for the “mitigation of fine wrinkles, mottled hyperpigmentation and lentigenes”

Most other formulations of topical retinoids can be sold with no claims other than that they “reduce the appearance of fine lines and brown spots.”  Differin 0.1% gel (adapalene) was recently approved by the FDA for the over the counter treatment of acne and became available at approximately $30/30 gm tube in January 2017.  The availability and price of this medication is a game changer in terms of topical retinoid treatment, not only for its approved use in the treatment of acne but also the non approved use for the treatment of sun damaged skin.  There is a large, prospective, randomized, controlled study showing improvement in actinic keratoses, solar lentigenes and photoaged skin with adapalene.  Refissa, if available at $106.91/20 gm, with its FDA indications for skin restoration is also a strong option.

From most evidence to least evidence for efficacy in the treatment of sun damaged skin, I rank the topical retinoids as follows:

  1.  Tretinoin and tazarotene
  2. Adapalene and retinaldehyde (Avene Retrinal 0.1%, $70/30 ml)
  3. Retinol

From least irritating to most irritating, I rank these products as follows:

  1.  Retinol
  2.  Adapalene and retinaldehyde
  3.   Tretinoin
  4.   Tazarotene

In terms of cost effectiveness, I rank them as follows:

  1.  Adapalene
  2.  Refissa or retinaldehyde
  3.  Tretinoin
  4.  Tazarotene

How to Use

To reduce skin irritation, and for maximum effect, I recommend the following:

  1.  Start using the product every other night for two weeks, then nightly if tolerated.  If necessary, take periodic breaks in the treatment.
  2.  Use gentle skin cleanser.
  3.  Use a moisturizer in the evenings and a facial moisturizer with sunscreen in the morning.  Simple unscented skin cleansers and moisturizers are best.
  4.  Apply the products lightly and evenly over the entire face, except around the eyes.

Topical retinoids will intensify the effects of chemical peels, microdermabrasion, or laser treatments and should be stopped at least one week prior to these procedures.