‘How can I prevent my skin from purging (having an acne flare-up) when I start using a topical retinoid?’

The dreaded tretinoin purge – this refers to a usually brief episode of a flare-up of pustular acne at the start of using a topical retinoid. I don’t see this in my patients very often but it is something widely discussed on blogs and on social media. The first thing is knowing why this happens: the new spots are probably due to how the retinoid works – it breaks down the stuck-together skin cells of the comedones (‘clogged pores’) quickly which results in the formation of a spot.

This is actually a sign that the retinoid is getting into the hair follicle unit and doing what it needs to do. (Bershad et al Cutis 1999). But it is disheartening and upsetting for patients at the start of treatment. So what can you do to prevent this from happening?

I suggest the following tactics (and this is potentially why many of my patients don’t experience this problem): Start with a low strength tretinoin or adapalene and start using it alternate days only for a few weeks and slowly increase to using it nightly I almost always use oral antibiotics at the same time as commencing a topical retinoid for acne which can potentially help reduce the risk of the ‘purge’ but also help clear the acne more quickly If you have a choice between adapalene or tretinoin, go for adapalene in the first instance if you are concerned about a purge.

Though all retinoids can lead to a purge, there is some evidence to suggest that adapalene has intrinsic anti-inflammatory activity which might make it less likely than tretinoin to cause a purge at the start of treatment (Grosshans et al, BJD 1998). The important thing to remember is to stick with your treatment despite the flare-up: it is important to know that this can potentially happen to you and to be mentally prepared for it. If it gets really out-of-hand, speak to your doctor about ways to minimise it.