Five Days of Topical Tretinoin for Acne

I have a great interest in patients’ adherence to treatment. Treatment to topical therapy is abysmal, making me think that our medications must work much better than we think they do, at least if they were applied regularly. For example, there is a general perception that topical acne medications work slowly. But have you noticed how often mothers of patients with acne seem to report, “You always catch it on a good day”? For years, I didn’t pay much attention to that, thinking it was coincidence, if I thought about it at all. But then Illinois dermatologist Dr Lester Fahrner clued me in to how You always catch it on a good day was simply a manifestation of how patients use their medication right before doctor visits (or the way people floss their teeth just before they go to the dentist). Acne medications must work very quickly, I thought, given that just a few days of use right before the visit results in us so regularly catching the acne on a good day.

I set out to prove how fast acne medications work with a simple “N of 1” experiment. I had acne on my forehead and samples of tretinoin in the clinic. At my Monday morning clinic, I took a photograph of the acne on my forehead and took a few small sample tubes of topical tretinoin home with me. My plan was simple: apply the topical tretinoin each night and record the dramatic improvement in the acne at the end of the week. The world (of dermatology) would be amazed.

But the plan was flawed. The first night, I forgot to put the tretinoin on. What a dummy!  The second night, I put into place a fool-proof system to assure that I wouldn’t forget; I put the tube of medication on top of my toothbrush. I brush my teeth just before going to bed every night without fail, and so this way I knew that I would use the medicine. When Tuesday night came around, I was at my sink with the tretinoin on top of the toothbrush in front of me, and I thought to myself, “OK, what should I do first, apply the tretinoin or brush my teeth?” If I put the tretinoin on first and then brush my teeth, I may splatter the toothpaste and have to wash my face and reapply the tretinoin. So, very reasonably, I decided I would brush my teeth first and then apply the tretinoin. I moved the tube of tretinoin just to the side, brushed my teeth, and then, as I always do, I went to bed, just like Pavlov’s dog.

On Wednesday, I went out of town to give a lecture. When I got to my hotel room after the talk, I realized I had forgotten to bring the medicine with me. By the time Friday arrived, when I had planned to get the post treatment pictures, I had not applied the tretinoin at all.

In this issue, we take a look at patient adherence and outcomes, especially when it comes to atopic dermatitis (page 50). As it turns out, we need to be a little more understanding with our patients, and sometimes this may mean being innovative in our approach to counseling them on their care plan.

Steven R. Feldman, MD, PhD
Chief Medical Editor