Acne in Pregnancy

By Dr Jane Leonard / 14 Jan 2019

Dr Jane Leonard provides an overview of the best-suited treatments to address acne vulgaris in pregnant patients

Acne vulgaris is believed to affect 80% of people aged between 11-30 in the UK.1 As an inflammatory skin condition, acne can cause significant damage to the skin on a mild to severe level; ranging from skin congestion to permanent scarring. It is the one condition that I see equally in both general practice and aesthetic practice, highlighting how common the condition is and how much it affects patients on a physical, emotional and psychological level.

For these reasons, I find that providing suitable solutions for patients presenting with acne to be extremely rewarding. That said, acne is still one of the most challenging conditions to treat and even more so in patients who are pregnant, appearing in one in two pregnant women.1 In my experience this is because many of those who are pregnant are unable to take many traditional methods for treating acne such as retinoids and some antibiotics.2

Acne and its causes

Acne is a chronic inflammatory skin condition that mainly affects the face, back and chest, with many patients having more than one area affected. It is characterised by the blockage and inflammation of the pilosebaceous unit of the skin, which consists of the hair follicle, its associated sebaceous gland and arrector pili muscle.2 The density of this unit is greatest on the face, back and chest, hence these are the skin surfaces which are most greatly affected by acne. The density of the pilosebaceous gland remains the same during pregnancy.

The pathogenesis of acne vulgaris is multifactorial. It is thought to involve many complex processes that occur within the skin that exacerbate each other, including:3

  • Altered follicular keratinocyte proliferation
  • Androgen-induced seborrhoea
  • Bacterial proliferation (predominantly propionibacterium acnes) within the sebum of hair follicles
  • Inflammation of the pilosebaceous unit

In addition to the causes above that effect the superficial layer of the skin, there are many other factors, both intrinsic and extrinsic, that play a role in the development of acne, such as the layer of the dermis, for example. High levels of androgens, in particular testosterone, which increases significantly when puberty kicks in, is a fundamental causative factor.3

Acne can present with lesions which can be non-inflammatory, inflammatory or a combination of both. Non-inflammatory lesions are comedones, which can be open (blackheads) or closed (whiteheads). Inflammatory lesions can present as papules or pustules. In more severe cases, inflammatory nodules can develop.4

Why is acne more common in pregnancy?

Women who have not previously suffered from acne are more likely to develop the skin condition in pregnancy. This is usually due to the high levels of oestrogen in the first trimester.6 Females who already have acne when they fall pregnant are more likely to develop a more severe case of their existing problem, and this is most common during the first trimester of pregnancy, again due to the high levels of oestrogen.6

Hormone changes, such as the increased levels of sex hormones oestrogen and progesterone, are the driving force behind the development of acne in pregnancy. Progesterone is more androgenic compared to oestrogen; it acts in a similar way to testosterone by stimulating the proliferation of the sebaceous glands and increases sebum production. This process causes the frequency of acne and severity of patients’ symptoms to increase. In some cases, the increased levels of sex hormones can become semi-permanent and persist post-partum. This is due to increased bacterial proliferation in the pilosebaceous unit, which can continue after the birth of the child.7,8

Consulting pregnant patients

The first and most important step in the consultation is to establish if the patient is pregnant and how many weeks she is. Patients may not always tell you directly that they are pregnant, as many may assume that you know already or not think it’s relevant, so try to make a point of asking this question early in the consultation and express the importance of a truthful answer.

The assessment process for pregnant women is very similar to those who are not pregnant. Firstly, you need to establish:

  • The duration of the acne
  • What areas of the body are affected
  • What types of lesions has the patient themselves noticed. Can you identify that there are mainly blackheads/white heads or are pustules the main problem?
  • Establish which treatments the patient may have previously tried already (both before and during pregnancy) and the response achieved. This is to ensure no teratogenic medications have been or are being taken by the patient
  • Possible exacerbating factors

The main exacerbating factor in this context is pregnancy and it is important for practitioners to confirm the stage of pregnancy that the acne first started.

Practitioners should also consider:

  • If the patient suffered with acne before they became pregnant
  • If they have a family history of acne
  • If they have a history of other hormonal problems that can also predispose them to developing acne, such as polycystic ovary syndrome
  • If they have changed their diet

The latter is particularly relevant in pregnancy as a woman’s diet may vary due to changes in food cravings and associated pregnancy-related conditions such as hyperemesis. This may mean women are excluding particular food groups from their diet or having a more restricted diet, as only certain foods can be tolerated. This is particularly common in the first trimester of pregnancy when oestrogen levels spore, potentially resulting in nausea and vomiting.9

Psychological effects

Sadly, the psychological effects of acne are often underestimated and misdiagnosed in many cases. The impact that acne has on self-confidence and self-esteem can be just as severe as the physical effects of acne on the skin.10 In my opinion, it is vital that aesthetic practitioners are empathetic towards patients who are suffering with acne and encourage them to be open with how the condition is making them feel. This is especially important in pregnancy as the hormonal changes that cause the initial flare-up in acne can also affect the patient’s mood.

Treatment

As extra care needs to be taken when treating women who are pregnant, there are many challenges that practitioners must be aware of to manage these patients appropriately.

I find that the most prominent challenges of treating acne in pregnancy are:

  • The increased potency of intrinsic hormonal causative factors (discussed above)
  • Treatments are limited as many drug and aesthetic treatments are teratogenic
  • There is limited data available related to the safety of many aesthetic treatments for pregnant patients

Treatment plans

As the medical and aesthetic treatment opinions are greatly limited during pregnancy, it is important to be open with patients about this prior to constructing a treatment plan for them. During this discussion, it is a good opportunity to identify the patient’s expectations so that you can manage these appropriately. Firstly, there are many simple things patients can do safely during pregnancy that can optimise their health and skin quality both during and after pregnancy. They mainly depend on the type of acne that the patient is experiencing, whether it be mild, moderate or severe.

Some patients may want to try as many treatment approaches as possible, as their appearance and psychological impact of acne may greatly affect them. Other women may only entertain more natural treatments and prefer to doing nothing until the baby is born. If she prefers to do less, always leave the door open for her to return in future, without pressure. Acne has such an emotional effect; especially during pregnancy. I believe it is vital we respect our patients’ decisions and support them at all times. For all patients, practitioners should advise that they avoid picking and squeezing their spots as this can spread bacteria, exacerbate inflammation and can cause scarring. They should also advise patients to use gentle skincare products that contain mostly natural ingredients, as over cleansing the skin can trigger an excess production of sebum to compensate for this.11 In addition, patients should use oil-free makeup and avoid products that are heavy on the skin surface, as oil-based products and emollients contain heavy molecules that cannot penetrate into the skin, for example products containing mineral oils and silicones, as these are comedogenic. They should also ensure their skin is adequately hydrated and that they consume a healthy, balanced diet.

Low risk treatments

As mentioned, the main limitation of aesthetic treatments when treating acne in pregnant patients is the lack of evidence in terms of safety. Many practitioners and aesthetic clinics tend to opt to avoid treating pregnant patients to be on the side of caution. The best interests of the mother and unborn child must always come first.

Many agree that topical treatments are the safest way to treat pregnant patients who are experiencing some form of acne. However, it is important to note that not all ingredients are deemed as low risk. Ingredients such as benzoyl peroxide, azelaic acid, glycolic acid and low concentration salicylic acid (patient dependent) are the only ones deemed as low risk and are suitable so I would incorporate into a treatment.18 Oral antibiotics that are safe to prescribe in moderate and severe cases include penicillin, erythromycin and cephalosporins.12 It is important to note, that prescribing prolonged courses of antibiotics can cause vaginal thrush, which is extremely common in pregnant patients.13

Treatments to avoid

Due to the lack of data, the safety of using aesthetic treatments, such as laser therapy, radiofrequency and chemical peels to address acne in pregnancy is uncertain. I would therefore recommend that these types of treatments are avoided.14-16

Treatments to avoid at all costs are topical retinoids such as tretinoin, topical isotretinoin and adapalene, as well as high concentrations of salicylic acid (patient dependent) – these are teratogenic and should therefore never be used.17 

The impact that acne has on self-confidence and self-esteem can be just as severe as the physical effects

 Oral antibiotics to avoid include:

  • Tetracyclines, such as doxycycline, minocycline and lymecycline – especially in the third trimester
  • Trimethoprim
  • Sulfamethoxazole
  • Fluoroquinolones18

The treatment which poses the highest risk for pregnant patients suffering from acne is oral isotretinoin. This should never be used to treat women who are pregnant, as it can potentially disturb the development of the embryo or foetus. Isotretinoin can be an effective treatment for severe acne, as it is a derivative of vitamin A and part of the retinol family.12

Conclusion

Practitioners must take extra care when treating patients who are pregnant. Due to the lack of data surrounding the safety of many treatment approaches for acne, I always say that it is better to be safe than sorry. Therefore, I would always avoid the use of laser therapy, radiofrequency, chemical peels, certain skincare ingredients and oral antibiotics and never prescribe isotretinoin. 

References

REFERENCES

  1. British Skin Foundation. New survey aims to reveal if acne is part of growing up or a cause of silent misery for millions. 2012. <http://www.britishskinfoundation.org.uk/LinkClick. aspx?fileticket=DAHfKofYgBg%3D&tabid=172>
  2. Ravenscroft J, Evidence based update on the management of acne, British Medical Journals, 2005 <https://ep.bmj.com/content/90/4/ep98>
  3. National Institute for Health and Care Excellence, Acne Vulgaris, 2018 <https://cks.nice.org.uk/ acne-vulgaris>
  4. DermNet NZ, Comedonal acne, 2014 <https://www.dermnetnz.org/topics/comedonal-acne/>
  5. Sarah Purdy, Acne Vulgaris, BMJ Clin Evid, 2008; 2008: 1714.
  6. Edede T, Arch E, Berson D, Hormonal Treatment of Acne. In Women, Journal of clinical and aesthetic dermatology, 2009 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2923944/>
  7. BMJ, Skin disease in pregnancy <https://www.bmj.com/content/348/bmj.g3489>
  8. BMJ, Sepsis in adults <https://bestpractice.bmj.com/topics/en-gb/101>
  9. Lee N, Saha S, Nausea and vomiting of pregnancy, Gastroenterology Clinics of North America, 2013 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676933/>
  10. American Academy of Dermatology, Acne can put a damper on hopes of glowing skin during pregnancy, 2014 <https://www.aad.org/media/news-releases/acne-can-put-a-damper-on-hopes-of-glowing-skin-during-pregnancy>
  11. DermNet NZ, Seborrhoea, 2014 <https://www.dermnetnz.org/topics/seborrhoea/>
  12. NICE, Browse Drugs, 2018. <https://bnf.nice.org.uk>
  13. Young G, Jewell D, Topical treatment for vaginal candidiasis (thrush) in pregnancy, 1999. <https:// www.cochrane.org/CD000225/PREG_topical-treatment-for-vaginal-candidiasis-thrush-in-pregnancy>
  14. Panchaud A, Csajka C, Merlob P et al. Pregnancy outcome following exposure to topical retinoids: a multicentre prospective study, Journal of Clinical Pharmacology <https://www.ncbi.nlm.nih.gov/ pubmed/22174426>
  15. Browne H, Mason G, Tang T, Retinoids and pregnancy: an update, The Obstetrician & Gynacologist, 2013 <https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/tog.12075>
  16. European Medicines Agency, Updated measures for pregnancy prevention during retinoid use, 2018 <https://www.ema.europa.eu/documents/press-release/updated-measures-pregnancy-prevention-during-retinoid-use_en.pdf>
  17. Cross R, Ling C et al, Revisiting doxycycline in pregnancy and early childhood, Expert Opinion on Drug Safety, 2016 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898140/>
  18. Pina Bozzo, Angela Chua-Gocheco, & Adrienne Einarson, Safety of skin care products during pregnancy, Can Fam Physician. 2011 Jun; 57(6): 665–667.
  19. Malvasi A, Tinelli A, Buia A, De Luca GF, ‘Possible long-term teratogenic effect of isotretinoin in pregnancy,’ Eur Rev Med Pharmacol Sci. 2009 Sep-Oct;13(5):393-6 <https://www.ncbi.nlm.nih.gov/ pubmed/19961047> 

Comments

Log-in to post a comment