Introduction

Acne vulgaris (AV) is a common chronic skin disease that causes both inflammatory (papules, pustules, nodules, and cysts) and non-inflammatory lesions (open and closed comedones). 

Female patients account for two-thirds of the acne visits to dermatologists and one-third of all such visits are by women 25 years and older.  Acne is associated with poor self-image, depression, and anxiety, all of which negatively affect quality of life.

Actinic keratosis (AK) is a common precancerous skin condition caused by long-term exposure to ultraviolet radiation that may progress to non-melanoma skin cancer. AK has a tendency to manifest on areas such as the face, head, and hands and because such lesions are highly visible and cosmetically unappealing, they may also negatively impact quality of life.

Numerous different treatment options exist, including topical medications, procedural modalities such as cryotherapy, dermabrasion, chemical peels, and laser resurfacing and photodynamic therapy. The choice of therapy is influenced by factors such as the number and distribution of lesions, lesion characteristics, patient preference for the mode of treatment, patient tolerance for side-effects (e.g. pain, inflammation, hypopigmentation, scarring), treatment availability, and cost. Two recent studies have suggested that 0.05% tretinoin cream may be a good choice to intercalate with classic treatments such as imiquimod and ingenolmebutate in the treatments of AKs9 and in the improvement of photoaging and stabilization of field cancerization.

Case report 

A 58-year-old woman presented with facial comedonal AV, AK of the face and neck, and selfreported complaints of dull complexion and dissatisfaction with her overall facial appearance.

At the time of her initial visit, cryotherapy with liquid nitrogen was used to treat 15 facial AK. Having ruled out fish protein allergies, she was prescribed tretinoin lotion, 0.05%. She was advised to apply a thin layer topically to her face at bedtime and minimize unprotected exposure to ultraviolet light including sunlight and sunlamps during treatment with tretinoin lotion. 

At 1-month follow-up, she had fewer acne lesions. There was significant improvement at her 3-month visit. 

She reported satisfaction with her response to treatment, in particular the reduction of acne and resolution of the perceived skin dullness. No treatment-related side-effects were experienced. She will continue treatment with tretinoin lotion 0.05% and the progress will continue to be monitored. She was advised to continue avoiding unprotected exposure to ultraviolet light. 

Discussion

Tretinoin lotion 0.05% contains micronized tretinoin particles together with skin hydrating ingredients: sodium hyaluronate, soluble collagen, and glycerin in a polymeric mesh matrix. Micronization is a valuable technique for products like tretinoin that have very low water solubility as it increases the dissolution rate by increasing the surface area. The micronization process results in reduced tretinoin particle size (~10µm versus 200–300µm in other tretinoin formulations) allowing for easier penetration into skin follicles, which are typically 11–66µm in diameter, with resultant direct uptake into sebum and greater deposition in the epidermis and dermis. 

The combination of moisturizers and humectants in the lotion vehicle enhances efficacy and improves tolerability. Sodium hyaluronate and collagen are powerful hydrating ingredients, while glycerin is a humectant, keratolytic that protects the skin against irritation and accelerates healing. 

Together, the polymeric mesh structure and vehicle lotion formulation help to improve skin barrier function, retain moisture, and decrease transepidermal water loss.

Several studies have demonstrated significant success of this new formulation in reducing inflammatory and noninflammatory lesions in moderate and severe female acne.

Tretinoin binds to and activates retinoic acid receptors, inducing changes in gene expression that leads to cell differentiation, decreased cell proliferation, and inhibition of tumor formation.²

In addition, pre-treatment of human skin with tretinoin blocks dermal matrix degradation followed by sun exposure, inhibiting the induction of the activated protein-1 (AP-1) transcription factor and AP-1- regulated matrix-degrading metalloproteinases.

Conclusion

Tretinoin lotion 0.05% is effective and well tolerated in the treatment of comedonal acne in this postmenopausal patient. 

Suggested Reading

1. Sangha, Archana. (2020). Treatment of post-menopausal acne with tretinoin lotion 0.05% delivers rapid results and concomitant benefits. SAGE Open Medical Case Reports. 8. 2050313X2092979. 10.1177/2050313X20929798.
2. Collier CN, Harper JC, Cafardi JA, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol 2008; 58(1): 56–59. 
3. Yentzer BA, Hick J, Reese EL, et al. Acne vulgaris in the United States: a descriptive epidemiology. Cutis 2010; 86(2): 94–99. 
4. Ramos-e-Silva M, Ramos-e-Silva S and Carneiro S. Acne in women. Br J Dermatol 2015; 172: 20–26. 
5. Hosthota A, Bondade S and Basavaraja V. Impact of acne vulgaris on quality of life and self-esteem. Cutis 2016; 98(2): 121–124. 
6. Gieler U, Gieler T and Kupfer J. Acne and quality of life— impact and management. J Eur Acad Dermatol Venereol 2015; 29 (Suppl. 4): 12–14. 
7. Weinstock MA, Lee KC, Chren MM, et al. Quality of life in the actinic neoplasia syndrome: the VA Topical Tretinoin Chemoprevention (VATTC) trial. J Am Acad Dermatol 2009; 61(2): 207–215. 
8. Criscione VD, Weinstock MA, Naylor MF, et al. Actinic keratoses: natural history and risk of malignant transformation in the Veterans Affairs Topical Tretinoin Chemoprevention Trial. Cancer 2009; 115(11): 2523–2530. 
9. Ianhez M, Pinto SA, Miot HA, et al. A randomized, open, controlled trial of tretinoin 0.05% cream vs. low-dose oral isotretinoin for the treatment of field cancerization. Int J Dermatol 2019; 583: 365–373. 
10. Sumita JM, Miot HA, Soares JLM, et al. Tretinoin (0.05% cream vs. 5% peel) for photoaging and field cancerization of the forearms: randomized, evaluator-blinded, clinical trial. J Eur Acad Dermatol Venereol 2018; 32(10): 1819–1826.
11. Weinstock MA, Bingham SF, Digiovanna JJ, et al. Tretinoin and the prevention of keratinocyte carcinoma (basal and squamous cell carcinoma of the skin): a veterans affairs randomized chemoprevention trial. J Invest Dermatol 2012; 132(6): 1583–1590. 
12. Kircik LH, Draelos ZD and Berson DS. Polymeric emulsion technology applied to tretinoin. J Drugs Dermatol 2019; 18(4): s148–s154.