Today we address a topic that many of you have inquired about - which is how to treat acne during pregnancy.

Pregnancy is a time when your body undergoes many rapid hormonal changes and a large majority - around 90% - of women notice changes in their skin.

While some women find their acne improves during pregnancy, others find that their acne worsens or that they get acne for the first time.

Though these changes will often disappear postpartum, acne can leave scars or post-inflammatory hyperpigmentation and so many women will want to treat pregnancy related acne.

Today we will go over what you can and can’t use to treat acne in pregnancy, and rest assured, there are treatments for acne that work for you during your pregnancy.

So, looking at the entire array of existing acne treatment, most are actually considered safe to use during pregnancy:

• Salicylic Acid at 2% concentration or less
• AHAs like glycolic and lactic acids
• Azelaic acid
• topical and oral erythromycin - these are antibiotics available by prescription only
• topical clindamycin - which is another antibiotic also available by prescription only
• And there is benzoyl peroxide - which seems to be somewhat in the gray area.

In terms of what’s considered not safe, it’s as you probably already know: the retinoids - oral or topical.

*To state the obvious: This article should not be used as a substitute for direct medical advice from your doctor or other qualified clinician.

FDA Classifications

Let’s first address that it’s generally advised that you err on the side of caution because quality data is scarce when it comes to pregnancy and skincare. And there is even less data regarding breastfeeding. The reason for this scarcity is simple: nobody wants to run tests on pregnant or nursing mothers.

So, let’s look at the data and opinions that are out there.

The FDA has a classification system for deeming what’s risky to the developing fetus. And this system incorporates both the degree of risk as well as what’s actually known in terms of hard data.

At the top is Category A - ingredients that have proven, well-controlled studies in pregnant women to show no risk of fetal abnormalities. Here is the thing, no ingredient for acne treatment is given a Category A rating. Due to lack of well-controlled studies.

At the bottom is Category X where adequate well-controlled or observational studies in pregnant women or in animal studies have demonstrated evidence of fetal abnormalities. The only ingredients given this category are Tazarotene and Isotretinoin, both retinoids.

Most ingredients are given designations of Category B, C, D and N and these incorporate a certain level of uncertainty. So this is why you may hear different advice from different dermatologists based on their level of comfort with this uncertainty.

Dermatologists will typically declare safe ingredients with a Category B rating. Category B is considered safe based on animal studies even if there is a lack of well controlled studies in pregnant women.

Some dermatologists will declare Category C ingredients unsafe, while others will be more nuanced and consider some safe and some unsafe during pregnancy depending on the ingredient. This is because Category C includes ingredients that have shown adverse effects in animal studies or ingredients where there is a lack of animal studies.

Category D is considered unsafe due to studies in pregnant women showing some risk to the fetus, but may be administered if the benefit outweighs the risk. Finally, category N means a lack of category as the ingredient has not yet been rated by the FDA.

We know this is confusing. The best thing to do is go ingredient by ingredient and learn the dos and don’ts.

Acne and Pregnancy

Now first off, acne is actually not the most common skin change to occur during pregnancy. The most common skin changes are hyperpigmentation and stretch marks. In many women, acne actually improves during pregnancy.

However, in others, acne can worsen in pregnancy or occur for the first time. Hormonal changes are known to contribute to acne breakouts but the exact mechanisms in pregnant women are not well understood (Pugashetti and Shinkai 2013). - which is why acne worsens in some but improves in others.

Treating acne during pregnancy requires some caution. Acne is typically treated with retinoids, benzoyl peroxide, salicylic acid, alpha hydroxy acids, azelaic acid, antibiotics, sulfone agents, and hormonal agents. But some of these ingredients should NOT be used during pregnancy.

Retinoids are a hard no,
Pause the use of retinoids if you’re pregnant.
Some prescription agents like antibiotics are also hard no’s as are hormonal agents and spironolactone but your prescribing physician will know these risks.

Other ingredients like salicylic acid and benzoyl peroxide are considered safe by some dermatologists but with caveats.

Finally ingredients like azelaic acid are both safe and preferred treatments for acne during pregnancy. Today we will go over these details.

Retinoids

Topical Retinoids are deemed unsafe to use while pregnant due to risk of birth defects from systemic absorption, i.e. your bloodstream.

Retinoids are Vitamin A derivatives, and Vitamin A is a necessary vitamin important for many functions in the body including proper fetal development.

The problem lies in the high amounts of Vitamin A that enter your circulation when you take retinoids. These high amounts lead to birth defects in your developing fetus, something called retinoid embryopathy. Retinoid embryopathy is characterized by facial and palatal defects, micrognathia, cardiovascular defects, and developmental problems of the central nervous system and thymus (Pugasheti).

Oral retinoids such as isotretinoin also known as Accutane are category X and considered particularly dangerous for the fetus since you are directly introducing high levels of Vitamin A into your systemic circulation. When Accutane was first introduced in 1982, there were hundreds of reports of birth defects that occurred as a result (AAD).

Topical retinoids used to treat acne include tretinoin also known as Retin-A, adapalene also known as Differin gel, and tazarotene also known as Tazorac. Popular anti-aging retinoids retinol and retinal found in a wide variety of over the counter serums and creams also have anti-acne effects but are not specifically indicated for acne treatment.

Topical tazarotene is especially to be avoided during pregnancy due to animal studies showing topical application led to birth defects and is Category X (Chien et al 2016). The data from adapalene and tretinoin are less clear and these are Category C ingredients. Clinical studies suggest that topical tretinoin does not raise overall serum Vitamin A levels nor does it lead to retinoid embryopathy (Panchaud et al. 2012, Pugasheti 2013).

Unlike isotretinoin where the doctor makes certain you are not pregnant while you are using it, topical retinoids are not regulated in terms of use by pregnant women which is how there is this data. In the case of Panchaud et al. 2012, this study was conducted in Europe.

In the decades of topical tretinoin use, there have been no confirmed cases of related fetal disruption in clinical trials (Beckenback 2015, Mukherjee et al. 2006). However, case studies (It's when a doctor somewhere in the world presents a case where such and such may have happened. So it's not a large scale clinical trial.) offer anecdotal evidence that topical tretinoin and adapalene use is associated with birth defects in rare instances (Bozzo 2011, Putra et al 2022). So it’s just not worth it.

Overall, considering there are so many other pregnancy safe options to treat acne, all retinoids during pregnancy are a definite no-no. It is not known if retinoids are excreted in breast milk (AAD).

Salicylic acid

Salicylates are a group of natural compounds found in many plants, including willow trees and wintergreens. They are commonly used as the active ingredient in pain-relieving medications such as aspirin, as well as in skincare products for their anti-inflammatory and exfoliating properties. Salicylates can also be found in various food items, such as fruits, vegetables, spices, and condiments, and can cause adverse reactions in people with salicylate sensitivity or intolerance.

salicylates are used in medicine. The most well-known form of salicylate is aspirin, which is used as a pain reliever and anti-inflammatory medication.

Aspirin works by blocking the production of prostaglandins, which are chemicals that cause pain and inflammation. In addition to aspirin, other salicylates such as choline salicylate and magnesium salicylate are also used as pain relievers and anti-inflammatory agents.

Salicylates can also be used in topical formulations to treat skin conditions such as acne, psoriasis, and warts.

Salicylic acid is a type of salicylate. It is a beta-hydroxy acid that is commonly used in skincare products for its ability to penetrate oil-rich follicles, making it effective in treating acne and other skin conditions.

Salicylic acid also has anti-inflammatory and exfoliating properties that make it beneficial for improving the overall appearance and health of the skin.

Salicylic acid is a beta hydroxy acid that is highly effective in acne treatment. However, it is considered Class C, and some dermatologists will err on the side of caution and tell you to avoid this ingredient while pregnant. This is because of the possibility of salicylate toxicity at high levels of salicylates in the bloodstream.

It is the same reason aspirin (acetyl salicylic acid) is not recommended during pregnancy. Aspirin is also not recommended during lactation as it carries the risk of causing bleeding disorders in the nursing infant.

For this reason even topical salicylic acid is considered Class C, because at high concentrations, animal studies show salicylic acid is harmful to the developing fetus. However, at lower levels of absorption into the bloodstream, it is considered safe (Chien et al. 2016).

The CIR sets the safety during pregnancy at 2% topical formulation based on absorption studies that show minimal absorption into the bloodstream at this concentration.

Beyond this 2% level, the safety is questioned So chemical peels where concentrations are much higher than 2% salicylic acid are a no no, but up to 2% in an OTC product applied on a limited area like the face is considered safe by many dermatologists. It is recommended to discontinue use during nursing and if used, to avoid applying to the chest area (AAD).

Benzoyl peroxide

Benzoyl peroxide is an antibacterial agent that kills P acnes, the bacterium implicated in acne development (AAD). It has unknown effects on a developing fetus and can enter into the bloodstream through the skin. Approximately 5% is absorbed into the bloodstream when applied topically.

Further, it is rated Category C as animal studies have not confirmed its safety and no studies have tested this ingredient in pregnant women. Hence, some dermatologists will err on the caution and say that one should avoid it (Chien et al. 2016). It is also not known whether benzoyl peroxide is excreted in breast milk (AAD).

However, it is known that benzoyl peroxide is metabolized to benzoic acid within skin and excreted unchanged (Putra et al 2022). Benzoic acid is a food additive known to be safe for pregnant women and so most dermatologists consider benzoyl peroxide safe for pregnant women (Bozzo et al. 2011, Murase et al. 2014).

The general recommendation is to talk to your obstetrician or dermatologist before using it while you're pregnant or breastfeeding.

Alpha Hydroxy Acids (AHAs)

Glycolic acid and lactic acid and other alpha hydroxy acids are often used alone or in concert with salicylic acid to treat acne. AHAs are rated class N by the FDA as in not yet rated, though animal studies showing no teratogenic effects (Chien et al. 2016, Putra et al. 2022).

Glycolic acid and lactic acid are not expected to be dangerous as only a small amount is absorbed through the skin and into the bloodstream. It is considered safe in pregnancy up to 10% with a pH more than 3.5 (Bozzo et al. 2011, Putra et al. 2022).

Azelaic Acid

Azelaic acid is an antibacterial and anti-inflammatory agent that is considered safe for pregnancy and is often the treatment of choice for acne during pregnancy.

Prescription azelaic acid at 15% or 20% is stronger, but more expensive than over the counter versions which are weaker at 10% and below.

It is Class B because animal studies show no harm to the fetus, but human studies are lacking. It is anti-microbial (good for acne) and inhibits the tyrosinase enzyme (good for hyperpigmentation) making it good for treating both acne and hyperpigmentation.

When applied topically, about 4% of the azelaic acid is absorbed into the bloodstream (Chien et al. 2016). Again, while there is little data in pregnant women, it is not associated with fetal effects in animal studies.

Further, it is a normal constituent of milk, and found in wheat, rye and barley. Hence, it is considered safe to use during pregnancy (Murase et al. 2014). It is minimally distributed into milk after topical application and so caution is advised while breastfeeding (AAD).

Antibiotics

Prescription only topical antibiotics such as clindamycin and erythromycin have been found to be safe for pregnancy and both oral and topical versions have been tested in studies with no indication of teratogenicity (Bozzo 2011). Erythromycin and Clindamycin are rated Category Class B (Chien et al. 2016, AAD guide). Combining these topical antibiotics with topical benzoyl peroxide improves treatment efficacy. It is unknown whether these topical antibiotics are distributed into breast milk and so caution is advised while breastfeeding (AAD).

Many oral antibiotics are not recommended during pregnancy, while others are known to be safe. Oral antibiotics such as tetracyclines cross the placenta and can result in bone growth inhibition. Tetracyclines (tetracyline, minocycline, doxycline) are class D. Further, they are known to be distributed in human milk. Hence, these are not to be used during pregnancy nor breastfeeding (AAD). The recommended oral antibiotics for use in pregnancy include (in order of preference) penicillin agents, cephalosporins, then erythromycin/ macrolide agents (Pugasheti et al. 2013). Amoxicillin which is a penicillin antibiotic and cephalexin which is a cephalosporin antibiotic are compatible with breastfeeding (AAD).

Sulfone Agents

Topical Dapsone is a synthetic sulfone agent with antimicrobial and anti-inflammatory properties and is considered category C. Due to the lack of studies, dermatologists will only prescribe in pregnancy if benefits clearly outweigh the risks (Chien et al. 2016). Dapsone is known to be excreted in human milk and so should be avoided while breastfeeding.

Spironolactone and other hormonal agents (oral contraceptives)

Spironolactone can treat hormonal acne and hirsutism due to its anti-androgen effects. Androgens are male sex hormones and women with high levels may get acne and hirsutism (facial hair, chest and back hair).

However, spironolactone should not be used during pregnancy as it can increase the risk of feminization in a male fetus (Murase et al. 2014). However, it is Category C in terms of risks to the fetus and is compatible with breastfeeding (AAD).

Oral contraceptive pills are also approved to be used in the treatment of hormonal acne but are Category X and should not be used during pregnancy (AAP).

Laser and Light therapy

Laser and light therapy can be used to treat acne although limited information is available about its efficacy. The most evidence exists for photodynamic therapy (PDT) (AAD).

These are generally regarded as safe to use in pregnancy but the numbing solution could affect the developing fetus. Hence, consult a dermatologist before getting treatment (Pugasheti 2013).

Complementary and Alternative Therapies

Herbal and alternative therapies like tea tree oil, have been used to treat acne. However, there is limited data on the safety and efficacy of these types of treatments, and they generally have not been rated for safety in pregnancy (AAD).

Some diets, especially high glycemic index diets, are associated with acne, with some limited evidence also suggesting some dairy, particularly skim milk, can influence acne. Dietary changes may therefore also be useful in acne treatment (AAD).

References

Bozzo P, Chua-Gocheco A, Einarson A (2011). “Safety of skin care products during pregnancy.” Canadian Family Physician 57: 665-667.

Chien AL, Rainer B, Sachs DL, Helfrich YR (2016). “Treatment of Acne in Pregnancy.” J Am Board Fam Med. 29: 254-262.

Murase JE, Heller MM, Butler DC (2014). “Safety of dermatologic medications in pregnancy and lactation.” J Am Acad Dermatol 70(3): 401.e1-e14.

Panchaud A, Csajka C, Merlob P, Schaefer C, Berlin M, De Santis M, Vial T, Ieri A, Malm H, Eleftheriou G, Stahl B, Rousso P, Winterfeld U, Rothuizen LE, Buclin T (2012). “Pregnancy outcome following exposure to topical retinoids: a multicenter prospective study.” J Clin Pharmacol. 52(12): 1844-1851.

Pugashetti R, Shinkai K (2013). “Treatment of acne vulgaris in pregnancy patients.” Dermatologic Therapy. 26: 302-311.

Putra IB, Jusuf NK, Dewi NK (2022). “Skin Changes and Safety Profile of Topical Products During Pregnancy.” J Clin Aesthet Dermatol. 15(2): 49-57.

Sumit K, Ajay K, Varma SP (2012). “Pregnancy and Skin.” J Obstetrics and Gynecology of India. 62(3): 268-275.

Tunzi M, Gray GR (2007). “Common Skin Conditions During Pregnancy.” 75: 211-218.

AAD: Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, Bowe WP, Graber EM, Harper JC, Kang S, Keri JE, Leyden JJ, Reynolds RV, Silverberg NB, Stein Gold LF, Tollefson MM, Weiss JS, Dolan NC, Sagan AA, Stern M, Boyer KM, Bhushan R (2016). “Guidelines of care for the management of acne vulgaris.” J Am Acad Dermatol. 74(5): 945-973.