Tretinoin side effects and purging: what to expect

Tretinoin is a prescription retinoid applied straight to the skin, and irritation comes with it. Redness, peeling, dryness and stinging are expected in the first weeks, and acne can look worse before it improves. The FDA labels for tretinoin are specific about what is normal and what isn’t. Here is what they say, how to ease the side effects, and when to call your clinician.

The common side effects

Irritation is the rule, not the exception. In the Renova 0.02% trials, which enrolled 339 people using it on their faces, almost every patient reported at least one local reaction, such as peeling, dry skin, burning, stinging, redness or itching. In 32%, the irritation was severe, led to a temporary pause, or led to a mild steroid cream; about 4% stopped Renova because of side effects (label).

In the Retin-A Micro 0.1% acne trials, irritation scores for redness, peeling, dryness, burning and itching peaked in the first two weeks and then decreased. No more than 3% had severe irritation, and 6% stopped because of it (label).

The generic label adds that true allergy to topical tretinoin is rare, and that so far all of its side effects have reversed when treatment stopped (label).

Purging: why acne can get worse first

The tretinoin cream label says that in the early weeks, “an apparent exacerbation of inflammatory lesions may occur. This is due to the action of the medication on deep, previously unseen lesions and should not be considered a reason to discontinue therapy.” That early flare is what people call purging.

The timeline on the labels:

• Weeks 1 to 2: irritation is at its worst (Retin-A Micro trials), and spots may flare.
• Weeks 2 to 3: the generic label says results should start to show; the Retin-A Micro label says after two weeks.
• Week 6 and later: more than 6 weeks may be needed before clear benefit, and the Retin-A Micro label says more than seven weeks for sustained benefit.
• Up to 6 months: for fine wrinkles on Renova.

If your skin is still getting worse after the first couple of months, or the breakout looks different from your usual acne, ask your clinician.

Sun sensitivity

Tretinoin makes your skin burn more easily. The labels say to keep sun exposure, including sunlamps, to a minimum, to use sunscreen and protective clothing, and not to apply it to sunburned skin until it has healed. The Retin-A Micro label sets the floor at SPF 15. People who work outdoors or burn easily should be especially careful, and wind and cold can add to irritation.

The Renova label also says not to use it alongside drugs that make skin more sun-sensitive: thiazides, tetracyclines, fluoroquinolones, phenothiazines and sulfonamides. Tell your prescriber what else you take.

How to reduce irritation

The labels give practical steps:

• Use a thin layer. More than directed doesn’t work faster or better and causes more redness and peeling, according to the Retin-A Micro and Renova labels. Renova’s label puts it at a pearl-sized amount, about 5 mm across, for the whole face.
• Wait after washing. Renova’s label says to wash gently with mild soap, pat dry and wait 20 to 30 minutes before applying.
• Wash gently. The Retin-A Micro label says to use a mild, non-medicated soap, not to wash too often or scrub, and to use a moisturizer.
• Go easy on other products. The generic label urges caution with medicated or abrasive soaps, drying cosmetics and products high in alcohol or astringents, and with products containing sulfur, resorcinol or salicylic acid.
• Space it out. If irritation is bothersome, the labels say to apply it less often or pause, then resume as your skin allows.
• Keep it off sensitive areas. Avoid the eyes, mouth, the corners of the nose and mucous membranes, and eczema.

Pregnancy and breastfeeding

Tretinoin is usually avoided in pregnancy, and you should tell your clinician if you are pregnant, trying to conceive or breastfeeding. Tretinoin taken by mouth is highly teratogenic. For creams, the Renova label says not to use it if you are pregnant, trying to become pregnant or at high risk of pregnancy. The newer Retin-A Micro label says published studies of topical tretinoin in pregnancy haven’t shown a link to major birth defects or miscarriage, but notes they have limitations, such as small sizes.

Combination creams carry the same caution. The Tri-Luma label, for a cream with hydroquinone, a steroid and tretinoin, calls tretinoin a teratogen and says 13 women became pregnant during its trials despite birth control (label).

Long-term use

Tretinoin is meant for ongoing use, but long-term data are limited. The Renova label says the safety of daily use beyond 52 weeks isn’t established, and that some people on Renova 0.05% for more than 48 weeks had atypical changes in skin cells and more dermal elastosis, of unknown significance. Ask your clinician how long to stay on it and whether to drop to less frequent use once your skin has responded; the generic label notes improvement may be kept with less frequent applications.

Compounded tretinoin creams

Many online providers sell tretinoin inside a compounded cream with niacinamide, azelaic acid or clindamycin. The tretinoin warnings still apply, and each added ingredient brings its own. Clindamycin labels, for example, warn that diarrhea, bloody diarrhea and colitis have been reported even with topical use (label). Compounded creams are not FDA-approved, and the FDA doesn’t review them for safety, effectiveness or quality (FDA). Ask your provider for the exact ingredients and strengths. See our custom compounded cream guide.

When to call your clinician

Stop and contact your prescriber if you have:

• Blistering, crusting, swelling or skin that becomes very red and raw.
• A reaction that suggests allergy or sensitivity.
• Severe irritation that doesn’t ease when you use it less often.
• Severe or persistent diarrhea, if your cream contains clindamycin.
• A pregnancy, or plans to become pregnant.

Online providers handle this differently. Curology lets you message your provider anytime and change your formula, Ro’s providers manage side effects and adjust treatment, and Nurx and Alloy include unlimited messaging. Our ranking of the best places to get tretinoin online compares them.

The bottom line

Redness, peeling and an early flare are expected on tretinoin and usually ease after the first two weeks. Acne results start to show after 2 to 3 weeks, though more than 6 weeks may be needed, and fine lines can take up to 6 months. Use a thin layer, protect your skin from the sun, and use it less often if it stings. Stop and call your clinician for blistering, swelling or a pregnancy. For doses and approvals, see the tretinoin medication guide, or start at our skin care hub.