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 that work for you during your pregnancy.
Looking at the entire array of existing acne treatments, most are actually considered safe to use during pregnancy:
Retinoids — oral or topical — are a hard no during pregnancy. This includes tretinoin (Retin-A), adapalene (Differin), tazarotene (Tazorac), retinol, and retinal.
This article should not be used as a substitute for direct medical advice from your doctor or other qualified clinician.
FDA Classifications
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.
The FDA has a classification system for deeming what's risky to the developing fetus. This system incorporates both the degree of risk and what's actually known in terms of hard data.
The best approach is to go ingredient by ingredient and learn the dos and don'ts — which is exactly what we'll do below.
Acne and Pregnancy
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 all retinoids if you're pregnant. Some prescription agents like certain antibiotics, hormonal agents, and spironolactone are also hard no's — but your prescribing physician will know these risks.
Ingredients like salicylic acid and benzoyl peroxide are considered safe by some dermatologists but with caveats. Azelaic acid is both safe and a preferred treatment for acne during pregnancy. Let's go over each in detail.
Retinoids
Topical retinoids are deemed unsafe to use while pregnant due to the risk of birth defects from systemic absorption — meaning entry into 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 the developing fetus, something called retinoid embryopathy — characterized by facial and palatal defects, micrognathia, cardiovascular defects, and developmental problems of the central nervous system and thymus (Pugashetti).
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 (Retin-A), adapalene (Differin), and tazarotene (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 — animal studies showing topical application led to birth defects place it in 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, Pugashetti 2013).
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 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.
Considering there are so many other pregnancy-safe options to treat acne, all retinoids during pregnancy are a definite no-no. It is also 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.
Salicylic acid is a type of salicylate — a beta-hydroxy acid that is highly effective in acne treatment due to its ability to penetrate oil-rich follicles. It also has anti-inflammatory and exfoliating properties that make it beneficial for improving the overall appearance and health of the skin.
Salicylic acid is rated Class C, and some dermatologists will err on the side of caution and tell you to avoid it while pregnant. This is because of the possibility of salicylate toxicity at high levels in the bloodstream — 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.
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 Cosmetic Ingredient Review (CIR) sets the safety threshold during pregnancy at 2% topical formulation, based on absorption studies showing minimal entry into the bloodstream at this concentration. Chemical peels with much higher concentrations are a no-no — but up to 2% applied to 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 the bloodstream through the skin — approximately 5% is absorbed topically.
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 side of caution and say to 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 the 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).
Talk to your obstetrician or dermatologist before using benzoyl peroxide while you're pregnant or breastfeeding.
Alpha Hydroxy Acids (AHAs)
Glycolic acid, 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 — meaning not yet rated — though animal studies show 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. They are considered safe in pregnancy up to 10% with a pH above 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, even though human studies are lacking. It is anti-microbial (good for acne) and inhibits the tyrosinase enzyme (good for hyperpigmentation), making it useful for treating both acne and pregnancy-related skin darkening.
When applied topically, about 4% of azelaic acid is absorbed into the bloodstream (Chien et al. 2016). 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 is found in wheat, rye, and barley — hence it is considered safe to use during pregnancy (Murase et al. 2014).
Azelaic acid is minimally distributed into milk after topical application, but caution is still advised while breastfeeding (AAD).
Antibiotics
Prescription-only topical antibiotics such as clindamycin and erythromycin have been found to be safe for pregnancy — 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, 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 (tetracycline, minocycline, doxycycline) are Class D, are known to be distributed in human milk, and 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 (Pugashetti et al. 2013). Amoxicillin (a penicillin antibiotic) and cephalexin (a cephalosporin antibiotic) are compatible with breastfeeding (AAD).
Sulfone Agents
Topical Dapsone is a synthetic sulfone agent with antimicrobial and anti-inflammatory properties, considered Category C. Due to the lack of studies, dermatologists will only prescribe it 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 Hormonal Agents
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 unwanted facial, 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). It is Category C in terms of risks to the fetus and is compatible with breastfeeding (AAD).
Oral contraceptive pills are also approved for the treatment of hormonal acne but are Category X and should not be used during pregnancy (AAP).
Laser, Light & Alternative Therapies
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 — so consult a dermatologist before getting treatment (Pugashetti 2013).
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 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 that certain dairy products, particularly skim milk, can influence acne. Dietary changes may therefore also be a useful complementary approach (AAD).
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