The application of topical retinoids (such as tretinoin) in the management of rosacea is complex. Because rosacea skin is sensitive and easily irritated, it is often advised to avoid topical retinoids, however retinoids are highly effective in certain clinical scenarios encountered in rosacea.
The most common scenario is the treatment of early-stage phymatous rosacea. Chronic inflammation causes the sebaceous glands to enlarge and the skin to undergo fibrotic tissue remodeling, leading to thickened, bumpy skin (most notably on the nose, known as rhinophyma). Retinoids are exceptional at remodeling collagen and normalizing skin cell growth. Careful application of a retinoid can help halt this tissue thickening and refine the irregular texture of the skin.
Additionally, many patients suffer from an overlap of true adult acne and rosacea simultaneously. In these cases, a gentle retinoid might be necessary to clear the comedonal acne.
If a retinoid is trialled, patients are should achieve excellent control of their rosacea first (for example with soolantra and oral antibiotics). Once stable, retinoids are initally applied in very small doses perhaps once a week, and always layered thickly over a rich, barrier-repairing ceramide cream to buffer the medication and prevent a flare.