Pregnancy and Lactation

A dermatologist’s guide to treating acne in pregnancy.

Although mostly associated with your teenage years, up to 50% of women over the age of 25 can be affected. During pregnancy, your acne often worsens because of large swings in your hormones.

Acne is a long-term skin problem that can present with whiteheads, blackheads, red bumps, and nodules mostly affecting the face, chest, and back. Acne is incredibly common, with up to 85% of people being affected at some point in their life. Although mostly associated with your teenage years, up to 50% of women over the age of 25 can be affected. During pregnancy, your acne often worsens because of large swings in your hormones.

Acne can cause a lot of mental health issues, which is particularly important right after delivery when postpartum blues and depression may develop and can have serious consequences. There are a lot of acne medications on the market but information about the effects of these medications on the developing baby is limited because pregnant and lactating women are usually left out from clinical trials. Most available information on the the potential for birth defects of these medications is obtained from cases of accidental exposure, where a woman used the products before she found out she was pregnant. In this article we will review how to to safely and effectively treat your acne during pregnancy and lactation.

Topical therapy

As a general rule, topical agents like creams and gels are safer than oral medications for use in pregnancy and lactation, because bloodstream absorption is minimal. Erythromycin, clindamycin, and metronidazole are antibiotic gels that are generally thought to be safe. When applied to the skin, bloodstream absorption is basically zero. The manufacturer of metronidazole gel, however, recommends caution during pregnancy because there have been a few reports of cancer in animal studies. Another newer medication is dapsone gel, but it is less well studied.

Retinoids are vitamin A based medications and include the very popular Retin-A and over the counter retinol. They are generally NOT considered safe in pregnancy, although large scale studies have not really shown an increased risk for birth defects when they are just used on the skin.  There is also no significant increase in miscarriages in women who used topical retinoids during pregnancy. Tretinoin (Retin-A) and adapalene (Differens) are probably safe in lactation because of very low levels of bloodstream absorption, but most dermatologists don’t feel comfortable prescribing them. Tazarotene (Tazorac) should not be used when breastfeeding because it is a much more potent drug and even a tiny amount of absorption is unsafe.

Azelaic acid is safe and effective during pregnancy and lacation .

Drugs like benzoyl peroxide, which is in a lot of over the counter acne medications, and azelaic acid have very little absorption, and can also safely be used in pregnancy and lactation. These medications are commonly combined with a retinoid like Retin-A, which can theoretically increase absorption, but in practice, the use of combination therapy in lactation is probably safe.

Medications by mouth

The antibiotic erythromycin by mouth has classically been the drug of choice when a strong acne medication is needed during pregnancy. Although mostly safe for use, there have been a few reports of fetal heart and liver problems. Azithromycin is another oral medication that is also safe and effective. Antibiotics like doxycycline and minocycline, which are commonly prescribed to non-pregnant women, should NOT be used in pregnancy because they can cause bone and teeth problems in your developing baby.

Zinc supplementation is a safe and effective way of controlling acne during pregnancy. Studies have consistently shown that at doses below 75 mg/day no harm is posed to the growing baby. Pretty much everything else by mouth is not safe in pregnancy especially the commonly prescribed medications isotretinoin (Accutane) and spironolactone. After pregnancy, while breastfeeding, an estrogen containing birth control pill is quite effective, especially if your acne is menstrual related.

Oral therapy may be needed for more severe acne during pregnancy .

Putting it all together

So, in conclusion, a suggested regimen for treating your acne during pregnancy and lactation would be: for mild to moderate acne use a once daily over the counter benzoyl peroxide or talk to your dermatologist about azelaic acid gel. Topical antibiotics like clindamycin or erythromycin are also safe. For more severe acne, erythromycin or azithromycin by mouth are safe in pregnancy and lactation. Zinc supplementation is also safe and effective for acne of any severity. Once you give birth, consider starting an estrogen based birth control if your are going to wait on having another baby, which can also help a lot. Of course, talk to your dermatologist before making any decisions, because there may be personal factors that would favor the use of one medication over another.

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