Does retinol make acne worse at first?

The popular name for acne that gets worse after starting a retinoid is purging. Drug labels and MedlinePlus do not use that word, and the sources do not agree with each other. Drug labels and MedlinePlus say acne may look worse in the first weeks of treatment. Two analyses of published trial data found no evidence of worsening. And none of these sources studies retinol for this question. Skinli sets out each view below with its source. The topic belongs to the larger guide to retinoids for acne, and the guide to skin purging vs a real breakout covers how to tell the two apart.

What the labels say

The over-the-counter Differin Gel 0.1 percent label says: "during the early weeks of use, your acne may appear to worsen before it improves (this is normal); continue using as directed, unless you get irritation that becomes severe." The prescription adapalene cream label says that during the early weeks of therapy, an apparent worsening of acne may occur.

The Retin-A label gives a reason. It says that during the early weeks of therapy an apparent worsening of inflammatory lesions may occur, and that "This is due to the action of the medication on deep, previously unseen lesions and should not be considered a reason to discontinue therapy." The Retin-A Micro label says the same and adds a condition: if the medicine is tolerated, initial worsening of inflammatory acne lesions should not be considered a reason to discontinue therapy.

What MedlinePlus says

MedlinePlus, the National Library of Medicine's drug information site, is more specific about tretinoin: "Your acne probably will get worse (red, scaling skin and an increase in acne sores) during the first 7 to 10 days that you use this medication. Continue to use it. The acne sores should improve in 2 to 3 weeks (and sometimes more than 6 weeks) of regular use."

For adapalene it says: "During the first weeks of your treatment, adapalene may bring previously unseen pimples to the skin surface. Continue to use adapalene even if your acne worsens or you do not see much improvement at first."

What two analyses of trial data found

A 2009 review from Wake Forest University asked whether topical retinoids cause acne to flare. It searched PubMed and the internet for sources that showed or refuted worsening. It reported: "No primary data from clinical trials were identified to support the dogma of acne worsening secondary to topical retinoids." It concluded that it is unlikely that acne worsens or flares because of topical retinoids, and that some acne patients may have worsening during the first week or two as part of the natural disease process.

A 2012 analysis in the journal Cutis looked at data from clinical trials of various adapalene gel formulations. It used two ways of counting a flare in the first week of treatment and reported: "In this analysis, no evidence of worsening or a flare was seen by either the VLS model or percentage-based definitions." The VLS model is a psychometric method, a visual logarithmic scale, used to evaluate perceived changes in inflammatory lesions. This analysis covers adapalene gel only. The PubMed records for both papers show no funding statement.

Why the sources differ

The sources do not explain the difference, and none of them says which view applies to a given person. What they agree on is the instruction: the labels and MedlinePlus say to continue, and the 2009 review says that any worsening in the first week or two may be part of the natural course of acne. The over-the-counter Differin label sets one limit: continue as directed unless irritation becomes severe.

How long it is expected to last

The timelines are broad. MedlinePlus puts early worsening in the first 7 to 10 days for tretinoin and says the acne sores should improve in 2 to 3 weeks, sometimes more than 6 weeks. The Retin-A Micro label says improvements may be noticed after two weeks but more than seven weeks may be needed for sustained benefit. NICE says positive effects of acne treatment can take 6 to 8 weeks to become noticeable. The Differin Gel 0.1 percent label says it may take up to 3 months of once daily use to see results. The guide to how long tretinoin takes to work sets out that drug's own timeline.

What about retinol

The labels and MedlinePlus describe early worsening only for the drugs adapalene and tretinoin, not for retinol. Retinol is sold in cosmetic products, and the evidence for it in acne is limited, as the guide to whether retinol works for acne explains. The AAD's page on testing skin care products says retinol can irritate skin, particularly sensitive skin, and calls that reaction normal and temporary. A 2022 study of benzoyl peroxide in the morning and retinol in the evening in 33 people reported no product-related side effects, but it is a single study with no comparison group mentioned in its abstract.

How to start so that irritation stays low

A slow start is advice for irritation. None of the labels or trial analyses shows that it prevents early worsening. The AAD says to use a retinoid every other night to start, and NICE says to start with alternate-day or short-contact application. The guides to starting retinol for acne and starting adapalene give the steps.

When to see a doctor

Deep, painful spots are a reason to see a doctor and not to wait. The AAD says that if you have large, painful pimples that sit deep in your skin, or acne that leaves a scar when it clears, you will need to see a dermatologist. The NHS says to see a GP if you have tried treating it yourself and it is not getting better, or if the spots are deep, painful or causing scars.