Acne and Pregnancy: A Clinical Review and Practice Pearls
Acne vulgaris is a common condition that routinely affects females of childbearing age. Taking into consideration the reproductive journey of women when treating acne is of paramount importance given the safety concerns to both the mother and the fetus associated with certain medications. Therefore, careful consideration of therapeutic choices during pregnancy is crucial. Herein, we summarize the safety of acne treatments during pregnancy and offer practical clinical pearls for routine dermatology practice.
Practice Points
- The management of acne in pregnancy requires careful consideration of therapeutic choices to guarantee the safety of both the mother and the developing fetus.
- The use of topicals should be observed as first-line therapy, but consideration for systemic therapy in cases of treatment failure or more severe disease is warranted.
- Discussion of patient expectations and involving them in decision-making for therapeutic choice is crucial.
Light-Based Therapies
Phototherapy—Narrowband UVB phototherapy is effective for the treatment of mild to moderate acne.75 It has been proven to be a safe treatment option during pregnancy, but its use has been associated with decreased folic acid levels.76-79 Therefore, in addition to attaining baseline folic acid serum levels, supplementation with folic acid prior to treatment, as per routine prenatal guidelines, should be sought.80
AviClear—The AviClear (Cutera) laser is the first device cleared by the FDA for mild to severe acne in March 2022.81 The FDA clearance for the Accure (Accure Acne Inc) laser, also targeting mild to severe acne, followed soon after (November 2022). Both lasers harbor a wavelength of 1726 nm and target sebaceous glands with electrothermolysis.82,83 Further research and long-term safety data are required before using them in pregnancy.
Other Therapies
Cosmetic Peels—Glycolic acid peels induce epidermolysis and desquamation.84 Although data on use during pregnancy are limited, these peels have limited dermal penetration and are considered safe for use in pregnancy.33,85,86 Similarly, keratolytic lactic acid peels harbor limited dermal penetration and can be safely used in pregnant women.87-89 Salicylic acid peels also work through epidermolysis and desquamation84; however, they tend to penetrate deeper into the skin, reaching down to the basal layer, if large areas are treated or when applied under occlusion.86,90 Although their use is not contraindicated in pregnancy, they should be limited to small areas of coverage.91
Intralesional Triamcinolone—Acne cysts and inflammatory papules can be treated with intralesional triamcinolone injections to relieve acute symptoms such as pain.92 Low doses at concentrations of 2.5 mg/mL are considered compatible with pregnancy when indicated.29
Approaching the Patient Clinical Encounter
In patients seeking treatment prior to conception, a few recommendations can be made to minimize the risk for acne recurrence or flares during pregnancy. For instance, because data show an association between increased acne severity in those with a higher body mass index and in pregnancy, weight loss may be recommended prior to pregnancy to help mitigate symptoms after conception.7 The Figure summarizes our recommendations for approaching and treating acne in pregnancy.
In all patients, grading the severity of the patient’s acne as mild, moderate, or severe is the first step. The presence of scarring is an additional consideration during the physical examination and should be documented. A careful discussion of treatment expectations and prognosis should be the focus before treatment initiation. Meticulous documentation of the physical examination and discussion with the patient should be prioritized.
To minimize toxicity and risks to the developing fetus, monotherapy is favored. Topical therapy should be considered first line. Safe regimens include mild nonabrasive washes, such as those containing benzoyl peroxide or glycolic acid, or topical azelaic acid or clindamycin phosphate for mild to moderate acne. More severe cases warrant the consideration of systemic medications as second line, as more severe acne is better treated with oral antibiotics such as the macrolides erythromycin or clindamycin or systemic corticosteroids when concern exists for severe scarring. The additional use of physical sunscreen also is recommended.
An important topic to address during the clinical encounter is cautious intake of oral supplements for acne during pregnancy, as they may contain harmful and teratogenic ingredients. A recent search focusing on acne supplements available online between March and May 2020 uncovered 49 different supplements, 26 (53%) of which contained vitamin A.93 Importantly, 3 (6%) of these 49 supplements were likely teratogenic, 4 (8%) contained vitamin A doses exceeding the recommended daily nutritional intake level, and 15 (31%) harbored an unknown teratogenic risk. Furthermore, among the 6 (12%) supplements with vitamin A levels exceeding 10,000 IU, 2 lacked any mention of pregnancy warning, including the supplement with the highest vitamin A dose found in this study.93 Because dietary supplements are not subject to the same stringent regulations by the FDA as drugs, inadvertent use by unaware patients ought to be prevented by careful counseling and education.
Finally, patients should be counseled to seek care following delivery for potentially updated medication management of acne, especially if they are breastfeeding. Co-management with a pediatrician may be indicated during lactation, particularly when newborns are born preterm or with other health conditions that may warrant additional caution with the use of certain agents.
