Dr. King also raises other concerns that prevent regulators from making tretinoin more widely accessible—namely, it’s an ingredient that could impact a fetus. When taken orally, retinoids (like isotretinoin, aka Accutane) have been found to potentially cause birth defects or miscarriage. It is not known if topical retinoids could pose danger to a fetus, but most dermatologists and OBGYNs don’t believe the risk is worth taking and recommend avoiding all retinoids—even weaker versions sold over the counter in the U.S.—during pregnancy.
Though this still doesn’t entirely explain the high cost in the U.S.
After speaking with a few dermatologists, I frankly didn’t come away with one clear answer on why tretinoin is at least three times as expensive in the US as some of the tretinoin available abroad. The doctors seemed to agree that the ingredient tretinoin itself is not costly. But other ingredients—the ones that make certain formulas more “cosmetically elegant,” in the words of Connecticut-based board-certified dermatologist Mona Gohara, MD—could drive up the price tag.
“Getting tretinoin is like buying a pair of jeans,” Dr. Gohara says. Differences in formulation and packaging among skin-care brands are just like the differences in stitching and fabric blends among denim brands. Different means of production lead to varying price points.
At least one dermatologist did also point to the profit-driven price hikes that we’ve seen from US pharmaceutical companies around other prescription products, like insulin and injectable epinephrine (the EpiPen). And Dr. King highlights the way American insurance companies weigh the value of covering claims for tretinoin, which is another factor that can affect how much a person might pay for it. Some insurance plans may require prior authorization before dispensing tretinoin, meaning a doctor needs to submit additional paperwork to the insurer to justify the prescription. Dr. King says she has noticed that insurance companies aren’t as likely to cover the cost of tretinoin if they think that patients are seeking it for cosmetic indications—like smoothing fine lines—rather than acne treatment.
Finally, other countries often have more government control over medication costs which could contribute to generic versions of tretinoin being more readily available and affordable. The market forces and patent protections we have in the US can make drugs pricier, sometimes prohibitively so.
Affordable tretinoin might not always be the safest or most effective tretinoin.
While I have been experiencing positive results from using tretinoin I purchased abroad (more on that in a second), every cream doesn’t fit all. “While affordable options abroad can be tempting, differences in formulation standards may impact safety and efficacy,” Dr. Gohara says. “It’s always wise to consult with a board-certified dermatologist who understands these nuances, especially for long-term treatments.” Dr. King echoes this sentiment and implores people not to be wooed solely by low cost. “I would always just give a word of caution about ingredients because I can’t vouch for what the policies are in different countries,” she says.