By: Seethal Sara Thomas, FNP-BC
Pregnancy is a time of changes for women and there are a variety of skin changes that may occur. A radiant pregnancy glow is flattering, but there are other and additional changes that may happen. The way skin will change during pregnancy is not guaranteed and the mechanisms by which pregnancy alters the course of acne is likely due to hormonal and physiologic changes (Ly, et al., 2023). One thing that is for certain is that acne treatment is often limited by potential toxicities of some of the most common and effective acne treatments (Awan & Lu, 2017). Acne affects a substantial portion of the population and has an increased likelihood to appear on women for all decades of life (Awan & Lu, 2017). Acne in pregnancy is usually inflammatory and is most severe during the second and third trimesters (Ly, et al., 2023). Acne treatments should take a stepwise approach and take into consideration trimester specific teratogenic risks, acne severity, relevant history, and psychosocial impact (Ly, et al., 2023). All acne treatments and remedies should be discussed and agreed upon between the patient and gynecologist. To provide a general overview of treatment of acne in pregnancy the treatments are organized into three categories: topical, oral, and physical based (Awan & Lu, 2017).
Topical: The approach to mild-to-moderate acne is generally with topical agents during pregnancy. Topical retinoids such as tretinoin and adapalene are contraindicated (Ly, et al., 2023). Topical tazarotene, hydroquinone, and toluene are not recommended during pregnancy. It is generally accepted that topical benzoyl peroxide, azelaic acid, glycolic acid and topical salicylic acid (2% or less) are safe to use in pregnancy. Topical antibiotics are used for inflammatory acne and reduce C.acnes on the skin. The most frequently used topical antibiotic is clindamycin which has low absorption but should be used with caution in patients with gastrointestinal disease because it has been associated with pseudomembranous colitis. Topical erythromycin seems to also have low absorption, but increased use of this antibiotic can lead to high rates of antibiotic resistance in the community and for that reason, other treatment may be preferred. Topical metronidazole and topical dapsone are second-line topical antibiotic treatments but dapsone must be discontinued before the last month of pregnancy (Ly, et al., 2023). All the topical antibiotics listed may have increased effectiveness when used with topical benzoyl peroxide.
Oral: If topicals are not enough to manage the acne, the next step to consider is oral treatments. To prevent antibiotic resistance, the regimen should be used in conjunction with benzoyl peroxide or azelaic acid. Oral retinoids, oral tetracyclines, spironolactone, oral prednisone, oral trimethoprim-sulfamethoxazole, and oral isotretinoin are not recommended during pregnancy. The preference for oral antibiotics is to initially treat with penicillins/aminopenicillins. If further pharmacologic management is needed, the next-in-line are cephalosporins, followed by macrolides (Ly, et al., 2023). Metronidazole is not a common medication used for acne, but it has been shown to be safe and may be useful in treating severe, refractory acne (Ly, et al., 2023). With oral treatments it is important to consider potential side effects and antibiotic resistance.
Physical based: Physical based treatments are usually considered with refractory acne. Aminolevulinic acid is not considered safe during pregnancy (Ly, et al., 2023). Intralesional corticosteroids may increase the risk of cleft lip and palate, especially if used in the first trimester. Narrowband ultraviolet B (NB-UVB) phototherapy is considered generally safe in pregnancy, but cumulative high doses of therapy may reduce folic acid levels so appropriate monitoring and supplementation should be given (Awan & Lu, 2017). Despite the efficacy and safety of NB-UVB, there may be barriers such as cost and accessibility to treatment (Myers, Kheradmand, & Miller, 2021).
Managing acne during pregnancy can be tricky, but an organized, stepwise approach can help create a safe and effective treatment regimen.
References:
Awan, S. Z., & Lu, J. (2017). Management of severe acne during pregnancy: A case report and review of the literature. International journal of women's dermatology, 3(3), 145–150. https://doi.org/10.1016/j.ijwd.2017.06.001
Ly, S., Kamal, K., Manjaly, P., Barbieri, J. S., & Mostaghimi, A. (2023). Treatment of Acne Vulgaris During Pregnancy and Lactation: A Narrative Review. Dermatology and therapy, 13(1), 115–130. https://doi.org/10.1007/s13555-022-00854-3
Myers, E., Kheradmand, S., & Miller, R. (2021). An Update on Narrowband Ultraviolet B Therapy for the Treatment of Skin Diseases. Cureus, 13(11), e19182. https://doi.org/10.7759/cureus.19182 Assessed and Endorsed by the MedReport Medical Review Board