WIMJ Guide: Retinoids against Acne & Clogged Pores

Retinoids can help you clear and prevent acne and clogged pores. The American Academy of Dermatology recognises retinoids as "the core of topical therapy for acne". This comes from hundreds of high-quality clinical trials. There is no doubt that retinoids work. But to get real results, you need to select the right retinoid product. You also need to adjust the rest of your skincare to support it. This often means using fewer of the other cosmetic products. Finally, you need to stick to your regimen for quite a long period of time to give the retinoid a chance to make a difference.

Note: This guide is an informational resource only. This is not medical advice. Please refer to a dermatologist for medical advice. Seek medical advice especially if your acne is severe and / or it prevents you from enjoying life.

Here we are talking about topical retinoids - that is retinoids applied on top of the skin, like a cream, serum, gel or lotion. They can do several things that help against acne. Topical retinoids can:

1. Reduce sebum (natural skin oil) production and even change the sebum composition. This reduces clogged pores & reduces the number of acne-triggering bacteria living on the skin.

2. Speed up cell turnover, including inside the pores, preventing pore clogging.

3. Reduce inflammation in skin - thus preventing and reducing inflamed blemishes.

The main and the most serious side effect of topical retinoids is that they can lead to skin irritation. If you are dealing with acne, you really don't want irritation in your skin. Irritation means an inflammatory response in your skin. Irritated skin is more likely to react with further inflammation, and we can get more new inflamed blemishes. Plus, irritated skin is simply not fun: it can get red, swollen, start flaking & peeling, get very tight and uncomfortable.

This is why the main part of creating an effective retinoid treatment regimen is to use an effective concentration of retinoid but without causing an irritation. It is a balancing act: the higher the concentration of a retinoid, the faster you might see the results. But also, the higher the concentration, the higher the irritation risk (and the results then are further away).

Contrary to a common belief, topical retinoids are not shown to have adverse effects for the baby development in pregnancy. (Retinoids taken orally as a pill do though). Still, doctors still often recommend avoiding topical retinoids in pregnancy out of caution.

You’ve probably heard this before, but this point is so important that it is worth repeating: You absolutely need a daily broad spectrum sunscreen with SPF 30 or higher if you are using a retinoid. Even if you are not using a retinoid, you still need it. Sunlight makes the post-acne marks darker and last for longer. It also makes post-acne scarring more likely. No one wants that, so using a daily sunscreen is the right choice. Even if it means making peace with a slightly dewy texture 😉.

“Skin purging” isn’t a proper dermatological term, but it still exists:). It is an increase in acne and clogged pores that can happen in the first 2-4 weeks after starting any skincare regimen that increases the skin cell turnover, like retinoids or exfoliating acids. If you are getting more acne the first weeks after starting a retinoid, it is probably it. Still, “listen” to your skin carefully: are you sure your skin isn’t getting irritated? If you suspect an irritation, give your skin an extra day free of retinoid and other actives. Also check the rest of your skincare routine: are you cleansing gently? Can it be that your sunscreen is contributing to irritation? (If yes, the next step is to change to a more irritancy-safe sunscreen, for example, a mineral-based one. Please avoid the temptation to stop using sunscreen altogether - you will get more trouble with post-acne marks without it).

If you think that what you are experiencing is not an irritation but “purging”, be patient and get through it - and continue the retinoid & sunscreen. You can add a spot treatment (for example, salicylic acid 2% or benzoyl peroxide 2.5%) to help you manage this period better. The “purging” should stop 6-10 weeks after starting the retinoid.

The causes of acne and treatment approaches for them are the same for any skin tone. But people with melanated skin need to be even more cautious about these two aspects:

• Avoid skin irritation. Irritation can lead to hyperpigmentation, and people with darker skin suffer from it more.

• Use daily broad spectrum sunscreen. Acne in people with darker skin is more likely to leave lasting pigmentation marks. Sunscreen helps prevent it.

For the same reason, it is more important for people with darker skin to treat acne early and seriously: you want to prevent as much inflammation and skin traumas from acne as possible. This will help avoid lasting post-acne marks.

What does it mean practically? Do not experiment with “natural” and “kitchen” remedies. Consider starting a retinoid regimen as soon as possible. But when starting the regimen, start with the lowest concentrations. Only increase the frequency and the concentration when you are certain that your skin isn’t getting irritated. Also, try to hold off introducing additional actives against acne before you are sure that you are tolerating the retinoid well. Finally, make sunscreen in the morning your daily habit.

If you get acne on your forehead, be extra-careful with your hair care products. Hair care products for thicker curly hair often contain ingredients that can cause irritation or clog pores.

The most important part of avoiding retinoid irritation is keeping your skin barrier strong. This includes:

• Cleansing gently (more on it here)

• Avoiding over-exfoliation (and even avoiding exfoliation at all if your skin is sensitive).

• Moisturizing twice a day (a basic moisturizer is enough, you don't need anything particularly fancy).

• Avoiding unnecessary irritants in your skincare. This includes fragrance, essential oils, most plant extracts, and formaldehyde-releasing preservatives.

• Not overusing other possibly irritating actives in your routine (for example, Vitamin C, Benzoyl Peroxide). It can also include some organic (so-called "chemical") UV filters, including Octinoxate, Isoamyl p-methoxycinnamate, Oxybenzone.

(You can add all the ingredients you'd like to avoid to your Avoid List on WIMJ).

The other part of avoiding the retinoid concentration is to choose the right concentration. When you are just starting with a retinoid, opt for low percentages. You can slowly build up your skin tolerance to retinoids, and might be able to use higher concentration with time without irritation.

The same goes for frequency. Start with applying your retinoid only a couple of times per week (2-3 times). Only if your skin feels well with it for the first 2-4 weeks, increase the frequency to every other day. If your skin is doing well with it, you can eventually use the retinoid once daily.

If your skin is sensitive, you can layer a moisturizer before and after your retinoid product. This will slow down the absorption and can help prevent irritation.

You can also protect the most sensitive parts of your face (for example, the area around eyes and lips) with fragrance-free vaseline. This will stop the retinoid product from getting to these sensitive non-acne prone areas.

Note: If you have access to a dermatologist, please follow their advice.

If you live in the US, the best retinoid option against acne (at least if you don't have access to a dermatologist) is Adapalene. It is a man-made molecule that was designed specifically to help treat acne. It is available over-the-counter in the US in 0.1% concentration. This concentration is effective.

If Adapalene is not available to you, the next best option is Retinal (Retinaldehyde). This molecule needs to go through some conversion steps in the skin before it can start doing its "magic" (while Adapalene can work straight away). It is available freely in most countries in cosmetic products. Retinal went through good clinical trials and is effective for treating acne. In addition to the typical helpful anti-acne effects of retinoids, it also has a direct action against the acne-triggering bacteria. Look for concentrations between 0.05% and 0.2%.

If Retinal is not an option, your next best choices are below. These three forms of retinoids were not studied properly for acne indication, but there are very solid grounds to believe that they can help with acne in a similar way as the other retinoids:

• Hydroxypinacolone Retinoate. Look for concentrations 0.2%-0.5%

• Retinol. Look for concentrations 0.3%-1%.

• Retinyl retinoate. Look for concentrations 0.3%-0.5%.

Yes, and combining different anti-acne actives can often bring faster results. But here is a caveat: more actives increase your chances of irritation. When in doubt, prioritize retinoids. For example, if you are using Benzoyl Peroxide and a retinoid in your routine, and you are starting to see irritation signs, you first need to give your skin a break from both. After the break (for example 3-14 days depending on how strong the irritation was), re-introduce the retinoid only. Later, you can also add the Benzoyl Peroxide again, but with less frequency.

What other anti-acne actives can you consider together with retinoids?

Let's start with actives that usually do not cause the irritation trouble. You can use them 1x or 2x daily without worrying about the irritation too much (of course, still watch your skin reaction):

• Azelaic Acid (10%-20%)

• Niacinamide (4%-6%)

• Linoleic acid (about 1%, almost non-existent irritation risk)

• Sodium ascorbyl phosphate (5%)

Actives with high irritation risk, especially when used in the same routine with retinoids:

• Salicylic Acid (2%). Limit the use to about 2-3x a week and as a spot treatment directly on inflamed blemishes.

• Glycolic Acid (4-10%). Limit the use to 1-3x times a week (if you are not using Salicylic Acid already). If choosing between Salicylic and Glycolic acid, go for Salicylic: it can exfoliate inside the pores and is more effective against acne.

• Benzoyl Peroxide (1%-2.5%). Only recommended if you get a lot of inflamed blemishes. Benzoyl Peroxide almost always leads to skin dryness. It is also best to limit the use of Benzoyl Peroxide to 2-4 months, until you improve the acne situation. It is not a good long-term option.

A standard treatment period for acne in clinical trials of topical retinoids is 12 weeks. This is the minimum time you should prepare yourself for before you expect to see meaningful results. There is no “standard” duration of the treatment: you can continue following your retinoid regimen as long as you keep seeing improvements. Once you feel that the acne is gone, it is a good idea still to continue using a retinoid for maintenance, but you can reduce the concentration and/or frequency.

Overall, it is a good idea to think about the retinoid regimen for acne in three stages:

1. Initiation. This is the period of the first 4-8 weeks when you are starting to use a retinoid. The goal here is not to go for a high concentration or frequent use, but rather to give your skin the time to get used to the retinoid. The slower you start, the less likely you are to get an irritation. As a rule of thumb, start with a lower concentration of the retinoid (if it is available, it’s not the case for adapalene which is usually only available in 0.1% concentration over the counter). Apply the product at night, 2-3 times a week. Increase the frequency gradually - and only if you do not get the irritation signs.

2. Active treatment. If your skin isn’t sensitive, you’ll get the most results with a daily use of the retinoid. If your initiation phase went well (no irritation), you can consider using a higher retinoid concentration. If you have had some signs of sensitivity, it is best to keep giving your skin “rest days” from the retinoid. This phase lasts at least 12 weeks, and until you feel that your acne issue is resolved or you stopped seeing any improvements.

3. Maintenance. It is a good idea to include a retinoid into your routine on a regular basis even after you’ve completed the “active phase”. It can help to prevent acne from coming back. You can go for a retinoid in a lower concentration and use it less frequently than during the “active phase”.

If you’ve been using a retinoid consistently for over 12 weeks and don’t see major improvements, it’s best to get a consultation with a dermatologist. You might need a different type of retinoid, a stronger concentration or a different approach altogether.

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