Acne in pregnancy

Treating acne in pregnant patients requires being proactive and willing to ask for help, said an expert.

Although it's difficult to find consistent figures, said Jonette E. Keri, M.D., Ph.D., of the University of Miami Miller School of Medicine, the high prevalence and psychosocial burden of acne in pregnant patients warrants dermatologists' best efforts. She is also chief of the dermatology service at the Miami VA Medical Center.

To set the stage for a healthy pregnancy, she advised getting acne as well-controlled as possible before the patient starts trying to conceive, and managing expectations throughout the treatment process. "Expectations are important because pregnant patients can't use everything they can use when they're not pregnant, so we are somewhat limited. On the other hand, we also want to help them. Talk to them at the beginning about these issues," and about the fact that treatment might not clear their skin, but it will help them feel better about their skin during their pregnancy.

Along with discussing expectations, Dr. Keri's treatment algorithm includes grading the patient's acne, using whichever grading system one prefers. "If acne is moderate to severe, consider systemic medications," and always document discussions. Her regimen typically includes mild nonabrasive washes containing glycolic acid, plus topical azelaic acid and clindamycin and oral antibiotics. She also recommends a physical sunscreen.

When counseling patients, Dr. Keri covers FDA risk categories. She starts by outlining the former FDA risk categories – A, B, C, D, X and N. Under the 2015 Pregnancy and Lactation Labeling Rule, "The new FDA categories are 'safe in pregnancy,' 'not safe in pregnancy' and 'uncertain (safety in pregnancy).' They're trying to put new medications into the new categories, and older medicines are being grandfathered in." Many doctors still use the old categories for guidance regarding acne medications because they find them helpful, said Dr. Keri. "And most acne medicines are old, and have the letters assigned to them."

Among first-line topical medications, she recommended those in category B (presumed safe based on animal studies) versus category C (uncertain safety – human and animal studies show no adverse events). Topical agents in the former category include azelaic acid, clindamycin, erythromycin and metronidazole.

Category C agents generally considered safe in pregnancy include the following:

• Benzoyl peroxide – Systemic absorption is minimal, and benzoyl peroxide is metabolized to benzoic acid (a food additive) in the skin, according to a review.
• Salicylic acid – Low-dose aspirin is used to treat preeclampsia. The key in acne is to use low concentrations over limited body surface areas, said Dr. Keri.
• Topical dapsone – Oral dapsone has been used to treat dermatitis herpetiformis in pregnancy, according to a report; topical dapsone is likely safe but studies are lacking.

Topical retinoids require caution. With tretinoin and adapalene, there have been case reports of otocerebral anomalies and anophthalmia with agenesis of the optic chiasma, respectively. Tazarotene is contraindicated in pregnancy. "We don't like to use topical retinoids in pregnancy. But if a patient has been exposed to a topical retinoid, you can tell them based on a retrospective study there's a very good chance it will have no effect on the baby."

The best and most widely used example of a category N (not classified) topical is glycolic acid, said Dr. Keri. It is believed to be safe in pregnancy, as only a minimal amount (up to 27% in an in vitro study) is absorbed systemically.

Category A systemic medications include zinc supplements, recommended at 30-200 mg daily. Although gastrointestinal disturbances can occur, one study shows no fetal harm from 75 mg daily of elemental zinc. Excessive zinc amounts, however, can lead to hypocupremia.

Category B systemic medications that have been used safely in pregnant patients with acne include cephalexin, cefadroxil, amoxicillin, azithromycin and erythromycin. Erythromycin estolate can be associated with hepatotoxicity in 10-15% of pregnant patients with prolonged use. Rare cases of pyloric stenosis have occurred in infants exposed to other forms of erythromycin.

One study looked at the safety of trimethoprim sulfonamide during the first trimester and found birth defects ranging from cardiovascular abnormalities (1.52%) to cleft lip/palate (0.10%). When compared to penicillins, cephalexin and no antibiotic exposure, however, trimethoprim sulfonamide had no statistically significant impact on the rate of these abnormalities, or of clubfoot and urinary system defects. "So you can reassure the patient that there's no increased risk of those side effects versus any other antibiotic."

A recent review showed a slightly increased risk of spontaneous abortion at less than 20 weeks' gestational age associated with macrolides (excluding erythromycin), quinolones, tetracyclines, sulfonamides and metronidazole in early pregnancy. However, said Dr. Keri, investigators did not consider the severity of patients' infections. "Having a serious infection might have been the reason for the spontaneous abortion," she said.

Dr. Keri recommended systemic prednisone (Category C) only for patients with severe acne and/or scarring. Most patients do well with 0.5 mg/kg or less per day, for a duration of weeks to months, she said. She also recommended combining prednisone with a systemic antibiotic and providing bone and gastrointestinal prophylaxis for pregnant patients on prednisone.

Treating pregnant patients with acne often requires asking for help, Dr. Keri added. "If a patient has significant scarring acne during pregnancy, reach out to the OB/GYN and say, 'What are you comfortable giving this patient? Are you comfortable with a steroid medication? An antibiotic?' Most times they're going to say yes."

Guidance can come from other dermatologists as well. "Don't just turn the patient away and say, 'I don't treat acne in pregnant patients.' There are practices that do that." Dermatologists who feel uncomfortable treating pregnant patients should at least give them a referral to an academic center or nearby expert, Dr. Keri said.

New FDA categories also characterize the safety of drugs during lactation. "If you're not sure about a medication being used by a woman who is lactating, ask a pediatrician to help you. Or have her ask her pediatrician."

Dr. Keri's take-home message is that "There are some very safe treatments that you can use during pregnancy. The ones people will probably feel most comfortable with are glycolic acid or benzoyl peroxide washes. Don't be afraid to treat. But if you don't want to treat pregnant patients, send them to somebody who will."

REFERENCE

F116 – The Pregnant Pause: How to Evaluate and Treat Your Pregnant Patients. "Treatment of Acne in the Pregnant Patient."  Jonette E. Keri, M.D., PhD., 4:15 PM, February 18, American Academy of Dermatology 2018 annual meeting.