Pregnancy leads to a range of skin changes among women. Some women experience no skin changes while others can experience severe acne, discoloration, or pigmentation. Acne is a common concern among pregnant women. Various treatments are available, but the safety of these modalities during pregnancy should be a concern. Current evidence for the safety of acne treatment is limited. A generalized overview of the various treatments used for acne and their safety in pregnancy is presented here. A brief overview of other skincare products commonly used during pregnancy and their safety concerns is also mentioned.
Most of the changes in the skin during pregnancy can be explained by an increase in the production of androgens in the body.1These changes may not be limited to acne and may also cause increased facial hair growth, skin pigmentation, and discoloration.2Medications for acne include retinoids, antibiotics, benzoyl peroxide, salicylic acid, and azaleic acid.3, 4These medications may be used orally, topically, or as ingredients in chemical skin peels.
Retinoids (Retin-A, Altinac, Atralin) are vitamin A derivatives and are prescribed for oral or topical use. Oral retinoids are known to be teratogenic and therefore must be avoided during pregnancy. They are known to cause a variety of birth defects including craniofacial defects, heart defects, and nervous system defects. Retinoids must be discontinued prior to conception for women desiring a pregnancy. Isotreinoin capsules (Accutane) is a commonly used tablet for acne treatment. It is absolutely contraindicated in pregnant women and women desiring to become pregnant. If a woman becomes pregnant while taking retinoids, the drug must be discontinued immediately.5For topical retinoids, there is some controversy concerning their teratogenicity despite generally low transdermal absorption. Some studies have suggested adverse affects associated with topical retinoid use while others have reported no hazards. Until there are larger studies yielding more research, topical retinoids should be avoided during pregnancy and in the preconception period.6-10
Antibiotics used in the treatment of acne include doxycycline, clindamycin, and erythromycin. Oral tetracylines are contraindicated during pregnancy due to potential for inhibition of bone growth. Topical antibiotics used for the treatment of acne include clindamycin (Cleotin T, ClindaDerm) and erythromycin (Erygel, Ery-Derm, Romycin). Studies have been performed to show the absorption of topical clindamycin. One study concluded that systemic absorption after topical use of clindamycin was not detected in the serum of patients using 2 ml of 1 percent clindamycin hydrochloride solution. However, it was detected in the urine of these patients in varying levels. This study concluded that 4-5 percent of topical clindamycin is absorbed transcutaneously.11Another study has shown that higher levels of clindamycin phosphate lotion result in systemic absorption than the clindamycin hydrochloride gel. Serum levels however were not of concern after twelve weeks. A third study used clindamycin preparation with zinc.12The levels were lower with zinc suggesting the protective effects of zinc against systemic absorption of clindamycin.13The same study studied the absorption of topical erythromycin. 60 to 70 percent of erythromycin was discovered on the skin after a period of application suggesting that only minor amounts are absorbed transcutaneously. There have been no reports of any increased side effects associated with pregnancy with the topical use of clindamycin and erythromycin.11
Benzoyl peroxide (Benzac, Alquam-X, Bencort, NeoBenz) is a topical agent also used in the treatment of acne. Because all peroxides are rapidly destroyed in the skin, benzoyl peroxide is minimally absorbed into the bloodstream. One study reports that only 3 percent of benzoyl peroxide applied topically is absorbed into the skin as metabolites.14There is no data currently published on the safety of benzoyl peroxide in pregnant women, however, since systemic absorption is minimal, current evidence suggests that it is safe during pregnancy.3
Salicylic acid (Aliclen, Fostex) is another ingredient of many skin care products. Salicylic acid in low doses ingested orally has provided no adverse affects to the fetus. Salicylic acid is used commonly in pregnancy in low doses to prevent preeclampsia. Therefore, the use of topical salicylic acid in pregnant women is considered safe.15
Glycolic acid (Aqua Glycolic) has shown to be damaging in animal studies. Is it an ingredient of many over the counter cleansers and lotions including Clear and Clear Cooling Daily Toner and Avon Anew Clinical Retexturizing Peel. Although the doses used in these studies was higher than the dose used in cosmetic products, it is best to avoid glycolic acid until further research has been done. Since the amount and concentration varies in various products as well as chemical peels, caution should be practiced by pregnant females when using glycolic acid. Azaleic acid (Azalex, Finacea) has not been studied in regards to pregnancy, but it is considered safe to use topically.16
Chemical peels are also performed for better skin as well as clearance of acne. More than one million chemical skin peels are performed yearly in the United States. Different types of chemical skin peels include glycolic acid, salicylic acid, tretinoin, trichloroacetic acid, or a combination of these agents. While topical glycolic acid should be avoided as mentioned previously, salicylic acid appears to be safe. As mentioned previously, Tretinoins are contraindicated in pregnancy, therefore peels containing retinoids should also be avoided. Trichloroacetic acid has limited research available for safety during pregnancy; however, recent studies suggest evidence of its carcinogenicity. Until there is more research on humans, trichloroacetic acid peels should be avoided in pregnancy.17Because of the unknown concentration of ingredients and various different combinations available, it is best to postpone chemical skin peels until after delivery.
Other products used frequently by women may include skin lightening agents, hair removal products, sunscreens, and cosmetics. Skin lightening agents that contain hydroquinone should be avoided in pregnancy because systemic absorption of hydroquinone is 30-40 percent after topical use18. Even though it has not been well studied in pregnant females and no adverse effects have been reported, because of the high systemic absorption, it is considered best to avoid skin-lightening agnets.19Hair removal agents for the face contain a variety of different ingredients, most common of these are calcium thioglycolate and potassium thioglycolate. Other than allergy concerns, there are no specific reported adverse affects for products used to remove facial hair. Sunscreens do not contain any known potential harmful ingredients for pregnant women. Make up used for the skin is composed of a myriad of various ingredients. Current data suggests that most make up products are safe to use during pregnancy.20
Although different skin care changes may be concerning to women during pregnancy, caution must be exercised in using products for treatment. A list of ingredients that must be avoided during pregnancy includes retinoids, hydroquinone, and trichloroacetic acid. Although other agents appear to be safe, the data for adverse events in pregnancy is very limited; therefore, it stands to reason to avoid products that have not been extensively studied in regards to potential harmful effects during pregnancy. Elective cosmetic procedures should be delayed until after delivery.21, 22
Saneea Almas, MD
InfantRisk Center
References:
1. Castracane VD, Stewart DR, Gimpel T, Overstreet JW, Lasley BL. Maternal serum androgens in human pregnancy: early increases within the cycle of conception. Human reproduction. Feb 1998;13(2):460-464
2. Akhavan A, Bershad S. Topical acne drugs: review of clinical properties, systemic exposure, and safety. American journal of clinical dermatology. 2003;4(7):473-492
3. Worret WI, Fluhr JW. [Acne therapy with topical benzoyl peroxide, antibiotics and azelaic acid]. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG. Apr 2006;4(4):293-300
4. Rothman KF, Pochi PE. Use of oral and topical agents for acne in pregnancy. Journal of the American Academy of Dermatology. Sep 1988;19(3):431-442
5. Accutane (isotretinoin capsules), 2015.
6. Jick SS, Terris BZ, Jick H. First trimester topical tretinoin and congenital disorders. Lancet. May 8 1993;341(8854):1181-1182
7. Lammer EJ, Chen DT, Hoar RM, et al. Retinoic acid embryopathy. The New England journal of medicine. Oct 3 1985;313(14):837-841
8. Loureiro KD, Kao KK, Jones KL, et al. Minor malformations characteristic of the retinoic acid embryopathy and other birth outcomes in children of women exposed to topical tretinoin during early pregnancy. American journal of medical genetics. Part A. Jul 15 2005;136(2):117-121
9. Selcen D, Seidman S, Nigro MA. Otocerebral anomalies associated with topical tretinoin use. Brain & development. Jun 2000;22(4):218-220
10. Shapiro L, Pastuszak A, Curto G, Koren G. Safety of first-trimester exposure to topical tretinoin: prospective cohort study. Lancet. Oct 18 1997;350(9085):1143-1144
11. Barza M, Goldstein JA, Kane A, Feingold DS, Pochi PE. Systemic absorption of clindamycin hydrochloride after topical application. Journal of the American Academy of Dermatology. Aug 1982;7(2):208-214
12. Hoogdalem EV, Baven T, Spiegel-Melsen I, Terpstra I. Trandermal absorption of clindamycin and tretinoin from topically applied anti-acne formulations in man. 1998;19(9):563-569
13. Chassard D, Kanis R, Namour F, al e. A s ingle center, open-label, cross-over study of pharmacokinetic comparing topical zinc/clindamycin gel (Zindaclin) and topical clidnamycin lotion (Dalacin T) in sujbects with mild to moderate acne. 2006;17(3):154-157
14. Yeung D, Nacht S, Bucks D, Maibach H. Benzoyl peroxide: percutaneous penetration and metabolis disposition. II, Effect of concetration. 1983;9:920-924
15. James AH, Brancazio LR, Price T. Aspirin and reproductive outcomes. Obstetrical & gynecological survey. Jan 2008;63(1):49-57
16. Andersen F. Final report on the safety assessment of glycolic acid, ammonium, calcium, potassium, and sodium glycolates, methyl, ethyl, propyl, and butyl glycolates, and lactic acid, ammonium, calcium, potassium, sodium, and TEA-lactates, methyl, ethyl, isopropyl, and butyl lactates, and lauryl, myristyl, and cetyl lactates. 1998;17(1 suppl):1-241
17. Guha N, Loomis D, Grosse Y, et al. Carcinogenicity of trichloroethylene, tetrachloroethylene, some other chlorinated solvents, and their metabolites. The Lancet. Oncology. Dec 2012;13(12):1192-1193
18. Wester R, Melendres J, Hui X, et al. Human in vivo and in vitro hydroquinone topical bioavailability, metabolism, and disposition. 1998;54(4):301-317
19. Mahe A, Perret JL, Ly F, Fall F, Rault JP, Dumont A. The cosmetic use of skin-lightening products during pregnancy in Dakar, Senegal: a common and potentially hazardous practice. Transactions of the Royal Society of Tropical Medicine and Hygiene. Feb 2007;101(2):183-187
20. Bozzo P, Chua-Gocheco A, Einarson A. Safety of skin care products during pregnancy. Canadian family physician Medecin de famille canadien. Jun 2011;57(6):665-667
21. Bayerl C. [Acne therapy in pregnancy]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete. Apr 2013;64(4):269-273
22. Lee KC, Korgavkar K, Dufresne RG, Jr., Higgins HW, 2nd. Safety of cosmetic dermatologic procedures during pregnancy. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. Nov 2013;39(11):1573-1586
