Tretinoin before and after: what trials found

The drug labels and guidelines behind this guide report tretinoin results as numbers, and none of them prints a before and after photo. In the acne trials on FDA-reviewed tretinoin labels, "before" was a count of spots on the first day and "after" was the same count at week 12. By then, people on tretinoin had on average 29 to 53.4 percent fewer inflamed pimples, depending on the trial. This guide reports those numbers at each point in time, and explains how to take fair photos of your own skin. For the drug itself, see the tretinoin guide.

Skinli gives general education and is not a doctor. Tretinoin is a prescription drug, and your prescriber picks the strength and the schedule. A trial reports an average across many people, so it cannot say what your own skin will do. The Renova cream leaflet says of that product that it "does not work for everyone who uses it."

How the trials measured before and after

The labels are published on DailyMed, the National Library of Medicine's database of drug labels. The acne trials on them followed one pattern:

• A count at the start. Staff counted two kinds of spots. The first kind is blackheads and whiteheads, which are clogged pores with no redness. The second is inflamed pimples, which are red bumps and pimples with pus.
• A rating. An examiner also rated each person's acne as a whole.
• A comparison group. Some people got tretinoin. The others got the same gel or lotion made with no drug in it. The Retin-A Micro and Altreno labels call their trials double-blind, which means neither the patients nor the study staff knew who had which.
• The same count and rating at week 12.

The Altreno lotion trials show who took part. The label describes them as "enrolling 1640 subjects age 9 years and older with acne vulgaris." Each person started with a grade of moderate or severe, 20 to 40 inflamed spots, 20 to 100 blackheads and whiteheads, and "two or fewer facial nodules." Nodules are the deep, painful lumps of severe acne, so these trials say little about that kind.

The spot counts at week 12

Each figure is the average percent drop in spots from the first day to week 12. The first number is for people on tretinoin. The second is for people on the same product with no drug.

Label and trial (people on tretinoin, people on no drug)	Blackheads and whiteheads	Inflamed pimples
Retin-A Micro gel 0.1 percent, Study 1 (72, 71)	49 against 22	37 against 18
Retin-A Micro gel 0.1 percent, Study 2 (72, 67)	32 against 3	29 against 24
Retin-A Micro gel 0.04 percent, Study 3 (108, 111)	37 fewer against 2 more	44 against 13
Retin-A Micro gel 0.04 percent, Study 4 (110, 103)	29 against 14	41 against 30
Altreno lotion 0.05 percent, Trial 1 (406, 414)	47.5 against 27.3	50.9 against 40.4
Altreno lotion 0.05 percent, Trial 2 (413, 407)	45.6 against 31.9	53.4 against 41.5
Ziana gel trials, the group on tretinoin 0.025 percent alone (846, 423)	31 against 16	39 against 26

Ziana is a gel that holds tretinoin and the antibiotic clindamycin. Its trials included one group that used tretinoin alone, shown above. The clindamycin and tretinoin guide gives the results for the combined gel.

How many people were clear at week 12

A lower count is one result. A clear face is another, and fewer people reached it.

Label and trials	What counted as the top result	Tretinoin	No drug
Retin-A Micro gel 0.1 percent, Studies 1 and 2	The study doctor rated the result "excellent"	35 and 28 percent	11 and 9 percent
Retin-A Micro gel 0.04 percent, Studies 3 and 4	The same "excellent" rating	14 and 19 percent	5 and 9 percent
Altreno lotion, Trials 1 and 2	Clear or almost clear, and at least 2 grades better than at the start	16.5 and 19.8 percent	6.9 and 12.5 percent
Atralin gel 0.05 percent, Trials 1 and 2	Clear, or the next grade above clear, on a 6-point scale. Trial 2 also asked for a 2-grade improvement	21 and 23 percent	12 and 14 percent
Ziana gel trials, tretinoin alone	Clear or almost clear	14 percent	8 percent

Three points follow from the two tables.

People on no drug improved too. In Altreno Trial 1, inflamed pimples fell by 40.4 percent with a lotion that held no tretinoin. The label gives no reason for that drop. It shows that part of any before and after change happens without the drug, and a single pair of photos cannot separate the two parts.

Most people were better and still had spots. The top result went to 14 to 35 percent of people on tretinoin. For acne treatment in general, the American Academy of Dermatology (AAD) says: "Complete clearing generally takes 3 to 4 months."

The rows cannot rank the products. Each trial had its own people and its own grading. The Altreno label says of side effect rates that those seen in the trials of one drug "cannot be directly compared to rates in the clinical trials of another drug", and the same care applies to these results.

What happens between the first day and week 12

A photo from week 3 or week 5 can look worse than the first one. MedlinePlus, the National Library of Medicine's patient site, says acne will probably get worse during the first 7 to 10 days of use. The tretinoin cream label says that in the early weeks, inflamed pimples may seem to get worse. Its leaflet adds: "BY 3 TO 6 WEEKS, some patients notice an appearance of new blemishes (papules and pustules)." Papules and pustules are two forms of inflamed pimple.

The same leaflet then describes "a continued improvement in your appearance after 6 to 12 weeks of therapy." The AAD's acne treatment page gives a similar time: "it takes at least 6 to 8 weeks before you start to see fewer breakouts."

For the full timeline, see how long tretinoin takes to work. The early worsening is covered in the tretinoin purging guide.

What changes, by type of spot or mark

Blackheads and whiteheads. The cream label says current evidence suggests tretinoin makes the cells that line the pore less sticky, so fewer tiny plugs form, and that it speeds up cell turnover, which pushes existing plugs out. The AAD says a retinoid, the drug family that tretinoin belongs to, "works to clear your pores, and can treat blackheads, whiteheads, and some pimples." In the trials above, the drop on tretinoin was 29 to 49 percent.

Inflamed pimples. The drop on tretinoin was 29 to 53.4 percent. The NHS in England says skin retinoids such as tretinoin "reduce inflammation and oiliness, and prevent spots".

Deep lumps. The Altreno trials took only people with two or fewer facial nodules. The AAD says that picking at or squeezing a nodule or cyst can raise the risk of infection, discoloration and scarring. If your acne is mostly deep and painful, read tretinoin vs isotretinoin and see a dermatologist.

Hormonal acne. The AAD's retinoid page says people with hormonal acne should see a board-certified dermatologist before they try a retinoid.

Dark marks. In a 1993 trial in the New England Journal of Medicine, 54 Black patients with dark marks left by skin inflammation finished 40 weeks of treatment. The marks lightened by 40 percent with tretinoin and by 18 percent with a cream that held no drug. Of the 24 people on tretinoin who finished, 12 developed skin irritation from the drug, which the study calls retinoid dermatitis. The guide to retinol and tretinoin for dark spots covers this use.

Skin color. The cream label says: "Temporary hyper- or hypopigmentation has been reported with repeated application of tretinoin." Those two words mean darker patches and lighter patches. The AAD adds that in skin of color, irritation can trigger dark marks.

Fine wrinkles. The Renova cream label reports four 24-week trials in people with lighter skin. Fine wrinkles showed no change in 40 percent of people on the cream and in 58 percent on a cream with no drug, and moderate improvement in 10 percent against 3 percent. Both groups used sun protection and moisturizer. The label states in capitals that the cream "DOES NOT ELIMINATE WRINKLES". See tretinoin for wrinkles.

Do the results last?

The sources link lasting results to continued treatment. The generic leaflet says: "Once your acne is under control you should continue regular application of tretinoin until your physician instructs otherwise." The label adds that "it may be possible to maintain the improvement with less frequent applications, or other dosage forms." MedlinePlus describes what happens after stopping: "If you stop using tretinoin, the improvement may gradually disappear."

The guide to what happens if you stop tretinoin reports the trials on stopping.

How to take fair before and after photos

Photos found online are hard to judge. The light, the angle, the makeup and the other treatments in use are often unknown, and no comparison group exists. Your own photos can be fair if you keep those things the same each time.

The AAD has a page on taking pictures of your skin. It says good photos help a dermatologist "determine how well your treatment is working." Its main points:

Element	What the AAD says
Light	"Natural, bright light, such as that coming in through a window. It works best." The light should shine on the skin and should not come from behind you
Background	"Stand in front of a solid-colored (one color throughout) wall or door."
Face	Remove any makeup from the area first
Camera	Make sure "all your camera filters are turned off (disabled)."
Check	Photos should be in focus and "Free of shadows, glare, and harsh lighting."

Then keep everything the same each time: the same spot, the same time of day, the same distance, a front view and one of each side. Take the first set before the first dose. The label trials counted spots at week 12, and NICE, the guideline body in England, reviews treatment at 12 weeks, so week 12 is the fair point for the "after" set. Photos at weeks 4 and 8 show the early weeks, when skin can look worse.

Skinli's guide on how to take acne progress photos explains the setup in full. Skinli's progress page is made for one photo a day in the same light and at the same angle, and the free acne score works from a single photo. The AAD says to ask your dermatologist how often to take pictures. Bring the photos to your review.

When to see your prescriber

Go back at the review your prescriber sets. NICE lists further steps for acne that has not responded well enough after 12 weeks, so a small change at that point is a reason to return and ask.

Go sooner for severe irritation, blisters or swelling, for deep and painful lumps, or for scars that are forming. The tretinoin side effects guide lists the reactions that the labels say need a call.