Moisturizer with tretinoin: before or after?

Moisturizer can be used with tretinoin, and several tretinoin labels ask for it. The labels place moisturizer after tretinoin or in the morning, and the American Academy of Dermatology (AAD) says a dermatologist may recommend moisturizer first when the drug irritates the skin. This guide shows what each label says, what the sandwich method is, and which words to look for on a moisturizer. For what the drug is and what it treats, see the tretinoin guide.

Skinli gives general education and is not a doctor. Tretinoin is a prescription drug in the US, and your prescriber picks the strength, the schedule and any change to how you apply it. This page covers tretinoin only. For retinol sold in stores, see moisturizer with retinol. For the label steps from washing to bedtime, see how to use tretinoin.

Why tretinoin labels ask for moisturizer

Dry skin is one of the most reported effects of tretinoin. The Atralin gel label is published on DailyMed, the National Library of Medicine's database of drug labels. In its trials, 16 percent of the 674 people on the gel reported dry skin, against 2 percent of the 487 people on a gel with no drug. Peeling was reported by 12 percent against 1 percent. The Retin-A Micro gel label lists "excessive dryness, redness, swelling, peeling" among the forms of irritation the gel can cause.

The AAD's page on moisturizer and acne names tretinoin among the acne treatments that "tend to dry and irritate the skin". It says: "Using a moisturizer every day can help your skin tolerate these medications." The same page gives a second reason. When skin becomes dry, it says, the body makes more oil, and the extra oil can clog pores.

Weather adds to the dryness. The generic tretinoin cream label says wind and cold may also irritate skin under treatment. The full list of skin reactions is in tretinoin side effects.

What each label says about moisturizer

Source	What it says about moisturizer
Generic tretinoin cream leaflet (the Retin-A leaflet has the same line)	Apply "a moisturizer or a moisturizer with sunscreen that will not aggravate your acne (noncomedogenic) every morning after you wash."
Retin-A Micro gel label	To reduce the risk of skin irritation: "Apply a topical moisturizer." The leaflet adds: "You may use moisturizers after applying RETIN-A MICRO."
Renova cream 0.02 percent, for fine wrinkles	"Skin moisturizers should be used at least every morning to protect the treated areas from dryness." No other skin care product for at least 1 hour after the cream
Altreno lotion label	When skin is irritated, prescribers are told to "instruct patients to use a moisturizer, reduce the frequency of the application of ALTRENO, or discontinue use."
Atralin gel label	For dry skin, "use of an appropriate moisturizer during the day may be helpful." The leaflet says: "You may use moisturizers and cosmetics."
Generic tretinoin gel (microsphere) 0.08 percent label	"Patients should apply a topical moisturizer if dryness is bothersome."
Tri-Luma cream (tretinoin with two other drugs, for dark patches called melasma)	"Patients may use moisturizers and/or cosmetics during the day."
MedlinePlus, tretinoin page	"Your doctor may tell you to use a skin moisturizer to help with dryness."

Every source in the table allows moisturizer. They differ on the time of day and on how long to wait.

Before or after tretinoin: three positions in the sources

In the morning. The generic leaflet and the Renova leaflet both name the morning, after washing. Tretinoin goes on at bedtime, so the two products are hours apart.

After tretinoin. The Retin-A Micro leaflet says moisturizers may be used after applying the gel, and it gives no waiting time. The AAD's page on the order of skin care products gives the same order: wash, apply any medicine "right after cleansing", then "Apply moisturizer and/or sunscreen." The Renova label is stricter. It says: "you are advised not to apply another skin care product or cosmetic for at least 1 hour after applying".

Before tretinoin. This position comes from the AAD's acne treatment page. It lists three changes a dermatologist may recommend to reduce irritation from a retinoid, the drug group tretinoin belongs to: apply a smaller amount, use the retinoid less often, and "Apply moisturizer first, especially if your skin needs a stronger retinoid." The page then says: "Only make these changes with your dermatologist's help." The tretinoin labels read for this guide do not describe moisturizer under the drug.

One more figure comes from a different retinoid. In the trials on the label for Aklief cream, which contains trifarotene, people were encouraged to use a moisturizer and to leave an interval of close to 1 hour before or after the cream.

Dry skin matters for the order. The generic tretinoin leaflet says of the wait after washing: "it is important for skin to be completely dry in order to minimize possible irritation." The AAD's moisturizer page suggests applying moisturizer while some water is still on the skin after washing. The morning, when no tretinoin goes on, is the time when both directions can be followed. If your prescriber tells you to moisturize before tretinoin at night, ask how long to wait between the two.

What the sandwich method is

The sandwich method is an informal name for three layers at night: moisturizer, then tretinoin, then moisturizer again. No FDA label, AAD page, NICE guideline or study read for this guide uses the name, and none tested the method.

Each half of it appears in the sources. Moisturizer first is on the AAD's list of changes a dermatologist may recommend. Moisturizer after is allowed by the Retin-A Micro and Atralin leaflets. A test of the two together is missing. No source read here measured whether a layer of moisturizer under tretinoin changes how much irritation people get, or how well the drug clears acne.

Several common questions about the method have no answer in these sources: how long to keep doing it, when to stop, and whether tretinoin can go over petroleum jelly or a thick ointment. Your prescriber can answer them for your skin and your product. Skinli gives no schedule of its own.

What to look for in a moisturizer

The sources describe a type of moisturizer and name no product, and Skinli names none here.

• Words on the container. The AAD says to look for one of three descriptions: "Oil-free", "Non-comedogenic" or "Won't clog pores". Non-comedogenic means made to avoid clogging pores. The Atralin label uses the same word: "Patients may use moisturizers that are noncomedogenic and should avoid products that could be drying or irritating." The guide to what non-comedogenic means explains it further.
• No oil base. NICE advises people with acne who use moisturizers and sunscreens "to avoid oil-based and comedogenic preparations." Comedogenic means likely to clog pores.
• Nothing that dries the skin. The generic tretinoin label asks for caution with "soaps and cosmetics that have a strong drying effect", and with products that hold high concentrations of alcohol, astringents, spices or lime. An astringent is a liquid sold to remove oil from the skin.
• Sunscreen in the morning. The generic leaflet allows "a moisturizer with sunscreen" for the morning step. The Renova leaflet says: "In the morning, apply a moisturizing sunscreen, SPF 15 or greater." SPF is the sun protection number printed on a sunscreen. The AAD recommends SPF 30 or higher, and says the sunscreen in a moisturizer still has to be reapplied every two hours outdoors. The numbers from each label are in sunscreen with tretinoin.

The base of the tretinoin product matters as well. The Retin-A gel base is 90 percent alcohol by weight, and Altreno is a lotion. The tretinoin cream vs gel guide compares the forms, and moisturizer for acne-prone skin covers textures and skin types.

What studies of moisturizer with tretinoin found

Two small studies tested a moisturizer in people using tretinoin. Only their abstracts, the short published summaries, were read for this guide.

Study	What people did	What the abstract reports
Journal of Drugs in Dermatology, 2006. 30 people taking isotretinoin capsules or using tretinoin on the skin	Applied a plain moisturizing cream twice daily for 15 days on one half of the face. The other half was left untreated	"a significant improvement in skin dryness, roughness, and desquamation" on the moisturized half. Desquamation means peeling
Cutis, 2006. Women with sun-damaged skin. The abstract gives no number of people	Applied two moisturizers, one on each side of the face, twice daily for 10 weeks. Tretinoin cream 0.025 percent started 2 weeks into the study	The authors report that a moisturizer made to support the skin's outer layer, started before tretinoin and continued, made the early phase of treatment easier

Both studies have limits. The first reports no count of pimples. The second had no acne group, and it compared two moisturizers with each other, so it cannot show what happens with no moisturizer at all. Neither abstract says whether the moisturizer went on before or after the tretinoin.

The larger trials behind the Renova label also included moisturizer. Every group, with or without tretinoin, followed a program of sun protection and "non-prescription emollient creams". Emollient creams are moisturizers. The label reports that "many patients in the vehicle group", the people whose cream held no drug, saw fine wrinkles improve on that program alone.

For acne, the AAD says "most patients see less acne between 4 and 8 weeks after beginning to use an acne friendly moisturizer." It adds that every patient in those studies also used an acne medication and a cleanser chosen by a dermatologist, so the moisturizer was one part of a plan.

Skin color is one more reason to limit irritation. A dermatologist quoted on the AAD's retinoid page says: "With skin of color, irritation can trigger dark marks, known as hyperpigmentation". She adds that a slow start and a moisturizer help to lower that chance.

When to see your prescriber about dryness

Some dryness and peeling in the first weeks is expected. The generic leaflet says early discomfort or peeling "usually subsides within 2 to 4 weeks." The guide to retinoid dryness and peeling covers daily care during that time.

A moisturizer has limits. Contact your prescriber in these cases:

• Irritation that is severe or lasts. The leaflet says: "If you are experiencing severe or persistent irritation, discontinue the use of tretinoin and consult your physician."
• Blisters, crusts or swelling. The label says the skin of some sensitive people "may become excessively red, edematous, blistered, or crusted." Edematous means swollen.
• Eczema. The Retin-A Micro label says to avoid the gel on areas affected by eczema, and the generic label reports severe irritation on skin with eczema.
• Sunburn. The leaflet says to stop tretinoin until sunburned skin has recovered.

For irritated skin, the label gives the prescriber three options: "use the medication less frequently, discontinue use temporarily, or discontinue use altogether." That choice belongs to the prescriber, and moisturizer is used alongside it. See a doctor or a dermatologist in person if your acne is no better after 12 weeks of treatment, which is when NICE says to review it, or at any time if you get deep, painful lumps or scars.