Tretinoin peeling: when a reaction is greater than expected^*

Dear Editor,

Tretinoin is a superficial peeling agent that has been used for a few years, with several clinical indications and low adverse effect levels.¹ It is quite popular in Brazil due to its effectiveness, safety and low cost. There are few studies on tretinoin peeling in the literature.² The ideal concentration is still undefined, therefore the use of concentrations between 1% and 10% is common.^1,2 References have been made for daily use at 0.25% concentrations, with safe and effective effects in photoaging treatment, by reason of its rapid skin retinization, with similar results to those of superficial peelings.³ For melasma treatment, reports have been made that the 5% concentration is as safe and effective as the 10% concentration for the improvement of MASI (melasma area severity index) and MelasQoL (Melasma Quality of Life Scale).² Complications are rare, and the most frequent ones are temporary erythema and scaling post-peeling.²

A 39-year-old woman's case is reported. She was monitored at the Dermatology Clinic to treat melasma, using 4% hydroquinone at night and 16% vitamin C, combined with broad-spectrum photo-protection in the morning. Afterwards, a 5% tretinoin peeling in hydroalcoholic solution containing propylene glycol was performed, and left for six hours. In less than 24 hours, the patient exhibited itching, accentuated swelling, and erythema on the entire face, with vesicles and blisters being formed in the chin area (Figures 1 and 2). The patient was treated with 40 mg of prednisone a day for five days, 500 mg of azithromycin a day for three days, and 0.05% desonide cream twice a day for 10 days. Progress was favorable, and full recovery occurred after seven days (Figure 3). The melasma did not worsen and there was no post-inflammatory hyperpigmentation. Patient presented a history of psoriasis vulgaris in remission, atopy, and exaggerated reaction to insect bites. In addition, she reported having allergic reactions to products with nickel and intolerance to products containing tretinoin, manifested by erythema and scaling. A patch testing was performed (Brazilian standard tray including cosmetics) and, at the 96-hour reading, it was positive for thimerosol (1+) and nickel sulfate (1+). Tretinoin was tested at 0.005% and 0.01% in an alcohol solution and 0.05% in vaseline. The test was positive for the 0.05% concentration only, with a reaction intensity of 1+ in both readings: at 48 and at 96 hours.

Figure 1
Accentuated face swelling and erythema

Figure 2
Details of vesicles and blisters in the chin area

Figure 3
Full improvement of the unexpected reaction to tretinoin peeling

The occurrence of a high intensity and a rapid onset of a dermatitis condition, with the formation of vesicles and blisters after the tretinoin peeling is still a relatively unknown event. No similar case has been reported in prior literature. Standardization of tretinoin patch testings is defective due to the irritating nature of retinoic acid. Different tretinoin concentrations were used in some case reports.^4,5 Despite its exuberance, the onset of this condition took place before 24 hours after the peeling application, and tretinoin positivity was only observed at the highest concentration, which maintained the same intensity of 1+ at the 48- and 96-hour readings, which suggests irritant contact dermatitis. Patient has been under dermatology follow-up, using topical medications, and submitted to salicylic acid peeling at 30%, without intercurrent events. Despite the intense adverse reaction, patient progressed to full recovery.

• Financial support: None
• *
  Work developed at the Dermatology Clinic at Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, MG, Brazil.

References

• ¹
  Cucé LC, Bertino MC, Scattone L, Birkenhauer MC. Tretinoin peeling. Dermatol Surg. 2001;27:12-4.
• ²
  Magalhães GM, Borges MFM, Queiroz ARC, Capp AA, Pedrosa SV, Diniz MS. Estudo duplo-cego e randomizado do peeling de ácido retinóico a 5% e 10% no tratamento do melasma: avaliação clínica e impacto na qualidade de vida. Surg Cosmet Dermatol. 2011:3:17-22.
• ³
  Kligman DE, Sadiq I, Pagnoni A, Stoudemayer T, Kligman AM. High-strength tretinoin: a method for rapid retinization of facial skin. J Am Acad Dermatol. 1998;39:S93-7.
• ⁴
  Tosti A, Guerra L, Morelli R, Piraccini BM. Contact dermatitis due to topical retinoic acid. Contact Dermatitis. 1992;26:276-7.
• ⁵
  Nordqvist BC, Mehr K. Allergic contact dermatitis to retinoic acid. Contact Dermatitis. 1977;3:55-6.

Publication Dates

• Publication in this collection
  Mar-Apr 2017

History

• Received
  09 May 2016
• Accepted
  11 July 2016