Trifarotene

By Dr Davin Lim

What is trifarotene?

Trifarotene is the very latest 4th generation retinoid for the treatment of both facial & truncal acne!... pretty exciting stuff! It was recently released in the U.S in 2020, & in Australia in 2021. The product is made by Galderma, who also makes Differin, Epiduo, & the Cetaphil range of products.

Trifarotene, unlike adapalene, is prescription only. It comes in a 75 ml container & costs around $90 AUD and can be prescribed by GPs & cosmetic GPs.

How prevalent is truncal acne? 

Very! According to studies, truncal acne affects over 50% of patients with facial acne. In most cases it is chronic & can lead to permanent acne scars, most commonly atrophic & hypertrophic scars. PIH or post-inflammatory hyperpigmentation is almost always associated with acne in darker skin types. Hence why it is so important to treat acne early & effectively.

What is unique about this retinoid?

In terms of research & approvals, this is the first topical retinoid approved for the management of acne on the face & trunk. Approval has been granted by the FDA in 2019 & TGA in 2021 meaning Australia is only behind by 2 years this time (up to 20 years for some drugs). Another unique point of difference is the fact that trifarotene is a specific gamma RAR agonist. This means a low concentration goes a long way.

How do I use it?

As with all retinoids, go slow. Start with application every second night & increase as tolerated. Unlike other retinoids, Akleif has no direct phototoxicity warning, however given the fact that it can compact the outer layer of the skin, it can indirectly make you more sensitive to the sun... so be sure to wear SPF as always!

Compatible ingredients include hyaluronic acid, moisturisers, niacinamide, & humectants. Caution with AHAs, BHA washes, & ascorbic acid.

What can trifarotene - Akleif treat?

The official guidelines in Australia have approved Akleif for the treatment of facial & truncal acne in anyone over the age of 12 and the FDA has approved for anyone over 8 years of age. Most dermatologists will employ this as off label treatment in younger patients if required.

I suspect there will be more studies regarding acne scar mitigation, much like how Galderma pushed Adapalene (Differin). Given it is a gamma RAR agonist (excuse the nerd lingo), it will also be useful for photo-ageing, anti-aging, fine lines, wrinkles & pore size reduction.

What do the papers say?

Multicenter studies with randomised vehicle vs product trials have shown a decrease of inflammatory acne lesions of 54 to 66% (two studies) at the 12-week mark.

Are there any side effects?

It is important to distinguish between expected effects and side effects. Remember, trifarotene is a retinoid, so expect retinoid like changes in your skin. Expected effects include:

• Skin flaking
• Skin sensitivity, redness & tolerable irritation
• Pruritus or itch skin
• Acne purging (as seen with most retinoids), self limiting
• Sun sensitivity
• Dry skin

The majority of retinoid induced skin changes can be mitigated by using moisturiser, altering dose & frequency, as well as time, but ultimately your medical dermatologist will guide you accordingly.

What is the concentration of trifarotene in Akleif?

As this is a specific gamma RAR agonist, the concentration of trifarotene is very low, namely 0.05%.

How much does it cost?

It depends on where you live. In Australia, Akleif retails for around $80-90 for a 75 ml container and depending on your level of cover, your insurance company may cover $30-$45. One 75 ml container is expected to last between 4 to 8 weeks (area dependent).

What are the other alternatives?

The decision to incorporate which retinoids into your skincare regimen is largely based on three factors - access to retinoids, your end goals & importantly your skin’s irritant threshold.

Other options include prescribed retinoids such as:

• Adapalene
• Tretinoin (retinoic acid)
• Tazarotene.

Over the counter (OTC) retinoids include:

• Retinol
• Retinyl palmitate,
• Retinaldehyde
• Prescription retinoids.

The next most powerful OTC topical which only requires one step conversion is retinaldehyde, followed by retinol and retinyl derivatives.

How do I incorporate trifarotene/Aklief in my skin care routine?

A sensible skin care routine that involves trifarotene goes something like this...

AM: Gentle wash, SPF, Make up, with the option of antioxidants (Ferulic acid, Ascorbic acid,  Vitamin E/Tocopherol).(BHA as tolerated)

PM: Cleanser, trifarotene. Option for moisturiser if required

*Be guided by your dermatologist. trifarotene/Aklief can be used as a stand-alone or as part of an acne treatment program (with anti-hormones & or antibiotics).

Davin’s Viewpoint on Trifarotene

It has been 20 years since a retinoid has been introduced to treat acne. Is the fact that it is FDA & TGA approved for the treatment of truncal acne the ground breaker? No. I think not. I do believe that other retinoids will give similar results, if not faster (I am talking about Epiduo as BPO has a faster onset of action compared to retinoids).

Where Aklief stands out is the gamma RAR specificity & the fact that it comes in a 75 ml container, hence a little goes a long way. Other retinoids come in smaller volumes & this may be impractical for larger surface areas. In Australia, the cost is around $90, half of which is covered by health insurance. Hence the actual cost is around a dollar a day. Pretty good value.

Disclaimer: I do not treat acne. My skill sets are concentrated on the management of objectively severe acne scars. For medical management of acne, consult my colleagues at Clinic Cutis.