Efficacy of Tretinoin vs Other Topical Therapies for Skin Photoaging

Tretinoin, or all-trans retinoic acid, remains dermatologists' gold standard for anti-aging treatment owing to its ability to stimulate epidermal growth and promote collagen production. Despite its remarkable ability to address multiple signs of photoaging, its tolerability remains a significant obstacle to patient compliance.

The authors of this article conducted a systematic review of studies comparing the efficacy of topical anti-aging treatments with that of tretinoin and found that, among 25 studies, more than half showed that the efficacy of tretinoin and comparator agents was equivalent, with the most common comparator being a different retinoid agent. They note various limitations of the studies, such as inconsistent reporting measurements, subject reporting bias, a wide variation in sample sizes, and omissions in statistical analyses. As the authors advocate for more randomized blinded studies, they also note that retinoid precursors, such as retinaldehyde, pro-retinal nanoparticles, and conjugated alpha-hydroxy acid and retinoid, can be utilized as a second-line therapeutic option.

As dermatologists, we are fully aware of the burning, stinging, irritation, and dryness that can be associated with retinoid use. We tell our patients to slowly dial up and down their use of retinoids depending on the changing seasons and avoid certain areas, such as around the eyes, where there is more delicate and thin skin. A "pea" sized amount may vary from person to person, but we counsel patients to mix the retinoid with a moisturizer, especially one containing ceramides (which may protect the skin barrier) or hyaluronic acid (which can help draw moisture into the skin and counteract the drying effects of a retinoid). The article fails to mention real-world practice; hence, when taking these factors into consideration, we may want to think about developing head-to-head clinical studies that allow patients to utilize tretinoin in conjunction with moisturizers. Additionally, newer formulations of tretinoin, including a lotion vehicle, have been developed, pairing microparticles of tretinoin with hydrating ingredients and taking into account patient sensitivities. Finally, there are some patients, such as those who are pregnant, for whom retinoid use would be contraindicated. Therefore, clinical trials comparing non-tretinoin anti-aging alternatives such as bakuchiol — a plant-derived extract (from Psoralea corylifolia) — may be useful.