Tretinoin

HARBOR SPRINGS, MICH. -- Topical tretinoin works if given a proper chance, Dr. John Kemerer said at the scientific assembly of the Michigan Academy of Family Physicians.

The main problem with retinoids, he said, is that they are often not given a fair trial by physicians and patients because they can take a while to work, and because of their side effects--namely irritation.

Proper management, with emphasis on keeping the patient informed, can do much to alleviate these problems, said Dr. Kemerer of Michigan State University College of Osteopathic Medicine, East Lansing.

Topical tretinoin is especially effective for comedomal acne. It can be used safely anywhere on the body where acne occurs. It comes in three strengths (0.025%, 0.05%, and 0.1%), but "most practitioners only use the 0.025%," he said.

Patients should start on the lowest strength, once daily, for 3 months, then move to twice daily and higher doses if needed. Patients need to know that their acne may get worse before it gets better. Encourage them to give it an adequate try--2-3 months. Tretinoin speeds up the 6-8-week acne cycle, "so the acne that was going to be on the face 2 months from now [will appear] in the next couple of weeks," Dr. Kemerer said.

The most common patient complaints are drying and redness. These can be minimized with instruction on how much to use--no more than a pea-sized dab for the entire face, two dabs for the chest, and three dabs for the back. "That's the biggest problem," he noted. "People tend to overuse it."

If the skin becomes irritated, encourage the patient not to stop treatment. A noncomedogenic moisturizer, such as Moisturel or Neutrogena, can be used. Some new products have built-in moisturizers to reduce irritation. Also, patients should avoid scrubbing their face or using harsh soaps before applying tretinoin. "They should use a mild soap and pat the face dry," he advised.

If the acne isn't improving adequately after 6-8 weeks, consider increasing the strength or frequency of application, or adding another topical product, such as benzoyl peroxide. Because benzoyl peroxide can inactivate tretinoin products, the two should not be applied at the same time, Dr. Kemerer cautioned. A good plan is to use benzoyl peroxide in the morning and the retinoid at bedtime.

Rise in Adult Acne

Be on the lookout for adult acne. You're likely to see more of it, Dr. Kemerer said.

"Family physicians don't pay much attention to adult acne, but as the population ages, we will be seeing more and more of it," he said.

Acne cosmetica, which tends to affect young women who use cosmetics that occlude pores, is particularly common in college graduates entering the working world. "The typical complaint is 'I've never had acne before,'" he said. Patients can stop using makeup or turn to noncomedogenic products. A short course of a topical antibiotic may be needed.

Pomade acne occurs almost exclusively in black patients who use a pomade that occludes pores around the hairline. Eliminate the pomade and treat with a topical antibiotic.

Occupational acne is caused by exposures to chemicals in the workplace, including cutting oils used in the tool and dye industry or, in the case of chloracne, chlorine. Treatment consists of protective clothing and ergonomic changes, such as better ventilation or face shields.

Acne keloidalis nuchal, a scar-like formation from trimming hair, is treated with interlesional corticosteroid injections or laser therapy.

Gram-negative folliculitis, an acute bacterial infection of the skin that often has to be detected by culturing, requires antibiotic treatment.

Steroid acne results from the use of high-potency topical corticosteroids--grade 4 or higher--on the face. To treat, taper the corticosteroid dose and use oral tetracycline.

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