Cosmetic Medicine in Japan -“Œ‹ž‘εŠw”ό—eŠO‰Θ- ƒgƒŒƒ`ƒmƒCƒ“iƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@AƒAƒ“ƒ`ƒGƒCƒWƒ“ƒOiŽα•Τ‚θj ƒgƒŒƒ`ƒmƒCƒ“(ƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@-“Œ‹ž‘εŠw- ƒgƒŒƒ`ƒmƒCƒ“(ƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@-“Œ‹ž‘εŠw-ƒgƒŒƒ`ƒmƒCƒ“(ƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@-“Œ‹ž‘εŠw-
Japanese pageEnglish page
ƒgƒŒƒ`ƒmƒCƒ“(ƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@-“Œ‹ž‘εŠw-
Web Master -Kotaro Yoshimura, M.D.-


ƒgƒŒƒ`ƒmƒCƒ“(ƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@-“Œ‹ž‘εŠw-

Instructions for patients undergoing tretinoin bleaching therapy

@

Tretinoin (all-trans retinoic acid), a derivative of vitamin A (retinol), is approximately 100 times more biologically active than vitamin A, and is the active substance of retinoids and corotenoids. Because everyone has a small amount of tretinoin flowing in their blood, tretinoin does not cause antigen-antibody reaction or allergic reaction in the human body.

Tretinoin is approved by the FDA in the United States as an agent for fine wrinkles and acne, and is widely used for rejuvenation of the skin. In Japan, it is not approved by Ministry of Health, but at the University of Tokyo Hospital we prescribe our original tretinoin aqueous gels (0.1%, 0.2%, and 0.4%), which are prepared by Department of Pharmacy, University of Tokyo.

(Note) Many cosmetics companies claim that creams containing retinol or retinyl esters have an effect on wrinkles. Retinol cream and retinyl esters combination is marketed about for 10 000 -20,000 yen in Japan, Since, however, retinol and retinyl esters have only about 1/100 the biological activities of tretinoin, they have actually no clinical effect; it can be said that they are not pharmaceuticals but cosmetics, and can be used only as moisturizing creams.

Tretinoinfs actions on skin:

1.Exfoliation (induce scaling).
2.Promote proliferation of keratinocytes, and accelerate epidermal turnover (differentiation of keratinocytes is also promoted).
3.Sebaceous gland function is suppressed; secretion of sebum is suppressed.
4.Collagen secretion is raised. Texture of the skin is improved, leading to improvement of fine wrinkles in the long term.
5.The secretion of mucinous substances such as hyaluronic acids in the epidermis is raised; the water content pf the skin is elevated.

In tretinoin therapy, tretinoin gels are applied by patient themselves. So, it is important that the patient understands the mechanism, normal treatment course, and possible side effects of the therapy well in order to obtain satisfying results.

The main side effects of this therapy: 1) irritant dermatitis, 2) post inflammatory hyperpigmentation. In order to minimize the dermatitis and to avoid post inflammatory hyperpigmentation, please undergo treatments under guidance of a physician.

(Important!) During tretinoin therapy, according to the indication of your doctor, go to the hospital regularly (usually every 2 weeks). If you receive the medicine and simply use at home without seeing a doctor, you may have unexpected skin reaction and/or unpleasing complications. The results of tretinoin therapy are not guaranteed.


@

‘ Principles of tretinoin therapy for pigmented lesions

The cells of the epidermis (keratinocytes) are born at the deepest layer of the epidermis (basal layer), and are pushed up gradually to the surface, eventually becoming the horny layer, and finally dirt. The lifecycle of the epidermis is called "turnover of the skin", and is known to take approximately 4 weeks.

In most pigmented lesions, the melanin pigments are located at the bottom layer (= basal layer). There is a cell which makes melanin called a melanocyte in this layer. Usually, in cosmetic whitening creams marketed publicly, an active ingredient whose function is to decrease the production of new melanin is included in very small amounts. In addition to the fact that the bleaching action of them is very weak, they cannot push melanin pigment out of the epidermis, so pigmented spots which already exist are not affected.

Tretinoin promotes the pushing of keratinocytes to the surface with melanin pigments. Tretinoin, which propagates keratinocytes, keeps keratinocytes being pushed up. Meanwhile, melanin pigments are also pushed up towards the surface, and are discharged in 2 to 4 weeks. This is a specific effect of tretinoin. With this treatment, hydroquinone suppresses production of new melanin in the melanocyte. So, when tretinoin and hydroquinone are used together, it means the pigmented epidermis will be replaced with a clean new epidermis.

‘ Main agents of the tretinoin bleaching therapy

  1. Tretinoin aqueous gel (yellow gel)
    This is yellow water gel, 98% of which is distilled water, and its base make the active reagent absorbed very quickly. There are several preparations with different strengths. Because they show very powerful action, you must use under the guidance of a doctor. This medicine pushes the melanin granules out of the old epidermis as dirt and the new epidermis is built up.
    Side effect: When you use, irritant dermatitis happens. Skin becomes red, and exfoliation takes place. This is not an allergic reaction to tretinoin, and, if it is moderate, there is no need to worry. It is one of signs indicating that the medicine is working. Especially when the reaction is strong, please consult your doctor.
  2. Hydroquinone lactic acid ointment (translucent color)
    Hydroquinone is an inhibitor of tyrosinase which is the melanin synthetic enzyme; furthermore, it is cyto-toxic to melanocytes which produce melanin pigment. Namely, it is a bleacher which suppresses production of the melanin pigment which is cause of the blotch. The lactic acid is one of the AHAs, which peels the skin mildly. Therefore, this ointment is a powerful cosmetic whitening ointment. The number of currently available whitening products such as albutine, kojic acid and placenta extract etc, is large, but the actions of those agents are very weak compared to hydroquinone (about 1/100). At these concentrations you cannot expect any real results.
    Side effect: Especially when undergoing treatment that removes horny layers, like tretinoin therapy, hydroquinone induces irritant dermatitis. When reaction is strong, do not discontinue hydroquinone, rather tretinoin should be halted temporarily. It is recommended to see your doctor ASAP.

    Oral medicine, moisturizer, skincare, oil and sunscreen cream, etc, may be necessary depending upon the type of blotch and the state of the skin. Please follow your doctorfs instructions.

    With hydroquinone contact dermatitis can appear. In these cases, the use of other bleachers such as kojic acid can be considered, but there are times when the bleaching effect fails.


‘
Classification of pigmented lesions

As for facial blotches, 5types of lesions sometimes exist on the face. After a doctor clinically diagnoses them, appropriate therapy for them will be started.

Below are typical facial blotch types:

lentigos

Many are sized from about 0.5mm to 3mm. There are black ones and brown ones.

pigmented nevus

Black spots which exists from birth.

melasma

On the cheek and forehead, symmetrical, flatlight brown macules.

freckles

Many small brown spots scattered on both cheeks and nose.

cafe au lait macules

From birth or adolescence, light brown, rather dense, there are also some which accompany black hairs.

solar (senile) lentigines

Appear after 30 years old and increase with age.  Dark or light brown, flat blotches whose outline can be clearly seen.

verruca senilis

Wart which appears with age. Raised, dark brown. Also called seborrheic keratosis.

postinflammatory hyperpigmentation

Pigmentation after inflammation of scratches, burns, acne, etc.


‘ What is tretinoin therapy effective for?

*

can be treated in a relatively short time

solar lentigines, postinflammatory hyperpigmentation, freckles

*

Things that becomes thin, but in order remove completely, time is required

melasma, cafe au lait macules

*

laser treatment should be combined

acquired dermal melanosis, verruca senilis, nevus of Ota, etc.



‘ How long will it take?

Usually facial blotch treatment period is approximately 2 months. In the cases of melasma and cafe au lait macules, the treatment period is longer.

‘ Treatment course

The treatment period is divided into two parts:  the first half is bleaching phase (2-6 weeks), the latter half healing phase (2-6 weeks). After starting, the treated skin becomes red and the skin peels. After that, redness increases gradually, but the blotch becomes thin. Most of the first 1-2 weeks is balance time, but after that the skin gets accustomed to the medicine, it keeps improving without either redness or stinging. During the first 2 weeks of bleaching, be sure to get examined by a doctor 1 time. The medicine is modified with every medical examination. If the skin gets too dry, please use moisturizer, oil, etc., in accordance with your doctorfs advice. Standard treatment period for blotches is 8 -12 weeks. After you improve, maintenance care is done 1 time after 2 months, or a 2nd round of therapy, if needed.

Be sure to read the following instructions before you start.

‘ Basic protocol

The basic protocol for facial blotches therapy is below:

  1. First, wash face with soap, the sebum is taken off. Try not to rub the skin too hard.
  2. Moisturize with non-alcoholic hypoallergenic moisturizer.
  3. Vitamin C lotion is applied evenly. High concentrations are recommended (for example: ascorbic sodium phosphate 10% lotion).
  4. Tretinoin aqueous gel (yellow gel) is applied thinly with a small cotton-tip applicator, let dry (1-2 minutes). Because it is strong medicine, pay attention to the points of caution below:
  5. If your doctor indicates, apply moisturizer as needed with your fingers.
  6. Apply hydroquinone lactic acid ointment (the ointment of translucent color) using your fingers, covering as widely as possible. Applying all over the face is OK. Be sure to use hydroquinone twice daily.
  7. In the morning, apply UV protection cream. Without rubbing strongly, please apply repeatedly. You can also use cream foundation or concealer for make-up. At night, you can cover with oil. Do not use milky and liquid type lotions.
  8. Lastly, in the morning, use UV protection powder. (not always necessary)
  9. The method of application above is used when starting the therapy. As therapy advances, contents of the medicine and method of application etc. may change a little. Please follow your doctor's instructions.

It is very important to receive this therapy under the guidance of a doctor. Please be sure to receive medical examination as needed because therapy and usage are sometimes modified by the doctor. When periodic observation is not done, unexpected or negative results can occur.

‘ General care

* Please be sure to keep the ointments in the refrigerator. Tretinoin, especially, breaks down quickly, so please get a new prescription every month.

* There is a difference in the reaction depending upon the part of the face.

Highly effective areas

Around the mouth and the eyes

Less effective areas

The T zone (there are times when high concentrations are needed)

 

@

* Please try not to use milky lotions etc. When there are some which you would like to use, please consult your doctor.

‘ To whom are pregnant or want to be pregnant

In animal experiments, tretinoin induced inborn deformities when used with large quantity doses. In people, the causal relation with topical use of tretinoin and deformities is not clear. Please use contraception during tretinoin treatment.

‘ Advice

Several types of blotches appear on the face. When senile lentigines are present, they should be treated first, because after getting used to this treatment, other blotches are relatively easy to treat.

In addition, if you have senile pigment spots on both the hands and face, we recommend treatment begins with the face. The reason, as mentioned later, is that hand treatment can be very difficult, so those who are already used to this remedy are more desirable.

‘ If scaling and redness are seen (two or three days after treatment start )

Usually not much happens in this treatment during the first 1 or 2 days.

However, when about 3 days pass, the skin becomes red and dirt or scales easily come off when washing the face.

This reaction is always present in treatment with tretinoin.  If treatment is discontinued, the skin gradually recovers.

Please pay attention to the following when the skin starts changing:

1) Moisturizing

 

During tretinoin therapy, because the horny layer of the skin peels off - the barrier of the skin - there is no moisture retention function. At treated sites, the skin dries. In addition, it is necessary to protect the skin from various stimuli and external enemies. Please do appropriate skin care according to your doctor's directions, such as moisturizing with liquid and oil.

2) UV Protection

 

It is easy to be affected by ultraviolet rays during tretinoin use. Therefore, if you do not adequately protect yourself from UV rays, you are basically inviting blotches. In accordance with your doctor's instructions, appropriate ultraviolet ray care should be used. Hypoallergenic sun screens and foundations etc are used. Especially in hot, sweaty times of the year, ultraviolet ray care becomes important in the daytime.

 

‘ Signs indicating you should suspend therapy

When the conditions below appear, please consult doctor before discontinuing tretinoin only.
  1. Pain is too strong.
  2. Occasional bleeding.
  3. Widespread irritation
  4. Skin becomes too red or edematous.

In addition, if you become anxious about the treatment, discontinue only the tretinoin, and consult your doctor as soon as possible.

‘ When skin does not become red after 1 full week of use

There is a possibility the concentration is not appropriate for your skin quality. Please consult your doctor.

@

Blotches of the hand

Hand blotch treatment is principally same as the face, but hand treatment is much more difficult. If there are face blotches as well we recommend that you treat them first, then the hands after getting used to tretinoin therapy.

Actually, Q-ruby laser treatment is recommended for hand blotches, and 4 weeks later, tretinoin therapy can be started for treatment of postinflammatory hyperpigmentation induced by the laser.

‘ Reasons hand blotch remedy is difficult:

    1. Applied ointment is easily removed by washing hands.
    2. The hand skin is less reactive to tretinoin due to the property of the skin. (less epidermal stem cells)
    3. The horny layer on the hand is thick.

‘ Notes when undergoing hand blotch treatment
  • As in case of the face above, please moisturize sufficiently.
  • When possible, we recommend that gloves, etc, made of cotton are worn.
  • Please do not forget to protect your hands as well from UV rays.

@


‘
Mechanisms of tretinoin therapy for acne

Acne is formed by accelerated function of the sebaceous gland and abnormal keratinization of hair follicles. Comedo is built up by abnormal keratinization and obstructs the normal discharge of the sebum. Tretinoin suppresses the function and induces atorophy of the sebaceous gland, and prevents acne by peeling off the comedo. Retinoids, such as tretinoin, are the first choice drug for acne in Europe and North America. @

‘ Basic protocol

Use 2 times a day (morning and night), or once a day at night. Follow your doctor's instructions.

  1. Wash your face.
  2. Apply vitamin C lotion.
  3. Apply tretinoin thinly and widely to the affected parts with the fingers.
  4. When your doctor indicates, apply AHA gel to the affected part(s).
  5. Apply moisturizer as necessary.
  6. In the morning be sure to use UV protection cream. Use make-up as normal.

The method of application above is used when starting the therapy. As therapy advances, medicine contents and method etc of application may change.

‘ General notes

*

Please be sure to keep the medicine in the refrigerator. Tretinoin, especially, breaks down quickly; please get a new prescription each month.

*

There is a difference in the reaction depending upon the part of the face:

  • Around the mouth (results happen a little at a time)
  • The T zone (there are times when high concentrations are needed)

*

Please try to take the prescribed medicine systematically regardless of your eating patterns.

*

Because irregular life and stress have an influence on acne, try to eat, sleep, and exercise regularly, and rest sufficiently.

*

Please try not to use milky lotions. If there are some you would like to use please consult your doctor.

*

After the acne improves sufficiently it is necessary to continue maintenance. After 2-3 months the redness also disappears.

*

Chemical peeling and deep abrasion can be done to treat acne scars after this treatment.



‘ To whom are pregnant or want to be pregnant

In animal experiments, tretinoin induced inborn deformities when used with large quantity doses. In people, the causal relation with topical use of tretinoin and deformities is not clear. Please use contraception during tretinoin treatment.

‘ If scaling and redness are seen (two or three days after treatment start )

Usually not much happens in this treatment during the first 1 or 2 days.

However, when about 3 days pass, the skin becomes red and dirt or scales easily come off when washing the face.

This reaction is always present in treatment with tretinoin.  If treatment is discontinued, the skin gradually recovers.

Please pay attention to the following when the skin starts changing:

1) Moisturizing

 

During tretinoin therapy, because the horny layer of the skin peels off - the barrier of the skin - there is no moisture retention function. At treated sites, the skin dries. In addition, it is necessary to protect the skin from various stimuli and external enemies. Please do appropriate skin care according to your doctor's directions, such as moisturizing with liquid and oil.

2) UV Protection

 

It is easy to be affected by ultraviolet rays during tretinoin use. Therefore, if you do not adequately protect yourself from UV rays, you are basically inviting blotches. In accordance with your doctor's instructions, appropriate ultraviolet ray care should be used. Hypoallergenic sun screens and foundations etc are used. Especially in hot, sweaty times of the year, ultraviolet ray care becomes important in the daytime.

 

‘ Signs indicating you should suspend therapy

When the conditions below appear, please consult doctor before discontinuing tretinoin only.
  1. Pain is too strong.
  2. Occasional bleeding.
  3. Widespread irritation
  4. Skin becomes too red or edematous.

In addition, if you become anxious about the treatment, discontinue only the tretinoin, and consult your doctor as soon as possible.

‘ When skin does not become red after 1 full week of use

There is a possibility the concentration is not appropriate for your skin quality. Please consult your doctor.


‘ Combination with hormone therapy

Most acne improves within 3 weeks after starting tretinoin therapy. There are times, however, even with tretinoin, when patients will develop new acne. In those cases, a combination therapy is recommended. You can use oral spironolactone (6 tabs) for 2 months. It will improve significantly new acne formation in the second month. Any other hormonal therapy such as oral contraceptives can also be combined with tretinoin therapy. Periodical blood tests for hepatic and renal function, as well as hormonal levels, are strongly recommended.

@



‚P‚Β‘O‚Μƒy[ƒW‚Ι–ί‚ι
Copyright -Cosmetic Medicine in Japan- “Œ‘ε•a‰@”ό—eŠO‰ΘAƒgƒŒƒ`ƒmƒCƒ“iƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@AƒAƒ“ƒ`ƒGƒCƒWƒ“ƒOiŽα•Τ‚θjƒgƒŒƒ`ƒmƒCƒ“(ƒŒƒ`ƒmƒCƒ“Ž_j—Γ–@-“Œ‹ž‘εŠw-