Biomarkers of Tretinoin Precursors and Tretinoin Efficacy in Patients With Moderate to Severe Facial Photodamage: A Randomized Clinical Trial.

1. JAMA Dermatol. 2022 Aug 1;158(8):879-886. doi: 10.1001/jamadermatol.2022.1891. Biomarkers of Tretinoin Precursors and Tretinoin Efficacy in Patients With Moderate to Severe Facial Photodamage: A Randomized Clinical Trial. Chien AL(1), Kim DJ(1)(2), Cheng N(1), Shin J(1)(3), Leung SG(1), Nelson AM(1)(4), Zang J(1)(5), Suh H(1)(6), Rainer B(1)(7), Wallis L(1), Okoye GA(1)(8), Loss M(1), Kang S(1). Author information: (1)Department of Dermatology, Johns Hopkins, Baltimore, Maryland. (2)Department of Immunology, Yale School of Medicine, New Haven, Connecticut. (3)Department of Dermatology, Inha University, Incheon, South Korea. (4)Department of Dermatology, Pennsylvania State University College of Medicine, Hershey. (5)Department of Dermatology, Weill Cornell Medicine, New York, New York. (6)Department of Dermatology, Ulsan University Hospital, Ulsan, South Korea. (7)Department of Dermatology, Medical University of Graz, Graz, Austria. (8)Department of Dermatology, Howard University, Washington, DC. IMPORTANCE: Topical formulations of tretinoin precursors (retinol and its ester derivatives) are widely available over the counter and may offer similar clinical benefits to those of tretinoin for treatment of photoaging. However, which of the many purported molecular effects of retinoids most strongly drives clinical improvements in tretinoin-treated skin remains unclear. OBJECTIVES: To evaluate the clinical efficacy of topical tretinoin precursors (TTP) vs tretinoin (RA) in treating moderate to severe facial photodamage and to identify potential biomarkers that correlate with clinical efficacy. DESIGN, SETTING, AND PARTICIPANTS: This randomized, double-blind, single-center, parallel-arm study of 24 patients with moderate to severe facial photodamage was conducted at an academic referral center from November 2010 to December 2011, with data analysis performed from January 2012 to December 2021. INTERVENTIONS: Daily topical application of 0.02% RA or 1.1% TTP formulation containing retinol, retinyl acetate, and retinyl palmitate for 24 weeks. MAIN OUTCOMES AND MEASURES: Photoaging and tolerability were assessed by dermatologist evaluations and patient-reported outcomes. Target gene expression was assessed by real-time quantitative polymerase chain reaction of biopsied tissue from treated areas. RESULTS: A total of 20 White women were ultimately analyzed (9 randomized to TTP, 11 randomized to RA). At week 24, there was no significant difference in Griffiths photoaging scores among patients receiving TTP vs RA (median, 4 vs 5) (TTP - RA difference: -1; 95% CI, -2 to 1; P = .27). Treatment with TTP was associated with erythema 6 times less frequently than RA (11% vs 64%) (TTP - RA difference: -0.53; 95% CI, -0.88 to -0.17; P = .01). Target gene analysis showed significant CRABP2 messenger RNA (mRNA) induction (confirming retinoic acid receptor signaling) but no significant changes in procollagen I or MMP1/3/9 mRNA in TTP-treated samples. Instead, MMP2 mRNA, which encodes a type IV collagenase, was significantly reduced in TTP-treated samples (week 24 - baseline mRNA difference: -5; 96% CI, -33 to 1.6; P = .02), and changes in MMP2 were strongly correlated with changes in fine wrinkles (r = 0.54; 95% CI, 0.12 to 0.80; P = .01). Interestingly, patients with severe baseline wrinkles exhibited greater improvements (r = -0.74; 95% CI, -0.89 to -0.43; P < .001). This trend was mirrored in MMP2 mRNA, with initial expression strongly predicting subsequent changes (r = -0.78; 95% CI, -0.89 to -0.43; P < .001). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, there was no significant difference in efficacy between this particular formulation of TTP and tretinoin 0.02%. However, the results of these mechanistic studies highlight MMP2 as a possible mediator of retinoid efficacy in photoaging. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01283464. DOI: 10.1001/jamadermatol.2022.1891 PMCID: PMC9178500 PMID: 35675051 [Indexed for MEDLINE] Conflict of interest statement: Conflict of Interest Disclosures: Dr Chien reported grants from SkinMedica during the conduct of the study; and grants from Amorepacific, Cearna, Inc, and Boots-Walgreens outside the submitted work. Dr Kim was a Paul and Daisy Soros Fellow and was supported in part by a grant from the National Cancer Institute of the National Institutes of Health (F30CA236466) and an MSTP training grant from the National Institutes of Health (T32GM007205) during the conduct of the study. Dr Okoye reported grants from Pfizer, and personal fees from Janssen, UCB, Novartis, and Unilever outside the submitted work. Dr Loss reported grants from SkinMedica during the conduct of the study. Dr Kang reported grants from SkinMedica during the conduct of the study; other (advisory board) from Allergan, Galderma, CeraVe, and Unilever outside the submitted work; in addition, Dr Kang had a patent for epidermal growth factor receptor inhibition for retinoid adverse effect prevention with royalties paid from Access Business Group, a patent for novel skin coating for UV protection pending, a patent for use of composition for treating rosacea issued, and a patent for composition and methods for use against acne inflammation issued. No other disclosures were reported.