Dr Ravi Brar explores the best ways to treat pregnant women presenting with acne
Acne is one of the most commonly presented skin conditions worldwide, with more than 90% of the world’s population affected by the condition at some point during their lives. It usually starts at puberty and varies in severity on areas of the face (99%), back (60%) and chest (15%).1 Acne is also a common in pregnancy. More importantly, for women who are planning a pregnancy or who are already pregnant, it can be bothersome due to the unpredictability of the condition and the fact that the most effective treatments are contraindicated. This is because of the ethical concerns of testing on pregnant women where treatments could always have the potential to cause harm to the foetus.2 Because of its complexity, it is important for practitioners to be aware of the best ways to assess and treat pregnant women who present with acne.
Acne is characterised by open comedones (blackheads) and/or closed comedones (whiteheads), in addition to papules and pustules (pus-filled spots). In cystic acne, patients develop more inflamed nodules and cysts.3 While acne can have a genetic predisposition, in most cases it is sporadic and occurs for unknown reasons. There is still debate amongst specialists as to why acne develops, but we know it is a disorder of the pilosebaceous unit (hair shaft, the hair follicle, the sebaceous glands, and the erector pili muscle).2,3
Whilst acne can develop in pregnant women who have never experienced it before, it is more likely to develop in individuals who had acne in their early years, typically occurring in their third trimester.2,4 This is thought to be due to an increasing level of androgen hormones, which are important to prepare the cervix for delivery,4,5 causing an increase in the skin’s sebum production and triggering the acne-formation cycle.5
Case studies have shown that acne lesions tend to be more inflammatory than non-inflammatory in pregnancy, and often have truncal involvement.5,7 A weaker immune system during pregnancy is one likely cause for this pattern of presentation.5,7,8
When thinking about the best treatment for acne it is imperative to carry out a thorough examination, during which five key features should be focused on:
1. Distribution: as acne is a disease of the pilosebaceous unit, the distribution will correspond to those areas with the highest density of the units e.g. the face, back and chest. On the face, lesions usually cluster on the chin, cheeks and forehead.4
2. Lesions: these can be divided into non-inflammatory and inflammatory, and any one patient can have a combination of different lesions. Non-inflammatory lesions can be closed where the follicular opening plugged with dark keratin and sebum is visible.6
Alternatively, the patient may have inflammatory lesions, meaning papules and pustules (superficial inflammatory lesions) or nodules and cysts (deep inflammatory lesions).4
3. Scarring: this can occur in those with severe acne and deep lesions (nodular/cystic), who delay their treatment or who pick or squeeze the spots. It occurs secondary to the inflammatory reaction and, when the body tries to repair the skin, can lead to uneven deposition of new collagen with excessive raised areas or insufficient depressed areas, continuous redness from dilated blood vessels, and post-inflammatory hyperpigmentation.9
4. Erythema: this is important as it may be present secondary to underlying inflammation, however telangiectasia is NOT a feature of acne alone.4 If present, practitioners should consider a co-existing condition, for example rosacea.
5. Severity: acne may be classified as mild, moderate or severe.
Comedones and inflammatory lesions are usually considered separately.6 In reality most medical professionals use their clinical judgement to define the severity, but these three classifications are used in research protocols.10
• Mild acne:
<15 inflammatory lesions
Or total lesion count <30
• Moderate acne: 20-100 comedones 15-50 inflammatory lesions or total lesion count 30-125
• Severe acne:
Total inflammatory count >50 or total lesion count >125
When discussing acne treatment in pregnancy, it has to be balanced with the severity of the condition and the safety profile of the treatment proposed. Topical therapies are generally accepted as the preferred treatment for mild to moderate acne, with more combination creams now available. Treatment ranges from topical through to oral medication in severe acne.
Various topical therapies that can be used to treat pregnant women include:
• Azelaic acid: has antimicrobial, comedolytic and mild anti-inflammatory properties.2 In addition, it helps to reduce pigmentation (10% concentrations are available over the counter, higher strengths of 20% require a prescription).2,5,7 Animal studies have shown <4% of the medication is absorbed systemically.2 It is often the first choice of topical treatment during pregnancy and has an added benefit of helping post-inflammatory hyperpigmentation.2
• Benzoyl peroxide (up to 5%): acts in a similar way to azelaic acid. Moreover, it helps to prevent the development of resistance when used in conjunction with antibiotics (topical and oral) as its antimicrobial property is through generating oxygen radicals.2 Animal studies have shown <5% gets absorbed systemically, which then gets broken down very quickly and cleared rapidly via the kidneys.2 This low absorption and rapid clearance means the potential risk in pregnancy is low.2
• Alpha hydroxy acid (AHA) fruit acids: glycolic acid helps to exfoliate the skin, thus eliminating follicular obstruction.7 Reports have shown that it helps in both inflammatory and comedonal acne.5 Moreover, it increases the skin absorption of other topical agents.7 Published reports have documented the safe use of topical glycolic acid in pregnancy. One such study reported statistically non-significant absorption of the acid in 25 pregnant rats, thereby indicating its safe use.6
• Antibiotics: it is important to remember not to use antibiotics as monotherapy due to the increased concerns of resistance. The two key antibiotics that are safe and commonly used are clindamycin and erythromycin (both topically and orally). 5 There have been no increased rates in adverse outcomes documented in several studies evaluating topical and systemic use of clindamycin and erythromycin in all trimesters.2,5,7 An example being a surveillance study by Biggs et al., which reported no increased risk of malformations among 647 women using oral clindamycin.5
Case studies have shown that pregnant patients with mild acne, suffering from primarily non-inflammatory lesions, respond well to topical azelaic acid or benzoyl peroxide.7 If there are inflammatory lesions, a supplementary topical antibiotic can and should be introduced.7 In fact, a combination of benzoyl peroxide and clindamycin is shown to be superior to using them individually and decreases the risk of antibiotic resistance.7
//THIRD SUBHEAD// Topical therapies to avoid
There are topical therapies not safe to use during pregnancy that practitioners should also be aware of, for example:
• Retinoids: there have been case reports of birth defects in babies from mothers who had prenatal exposure, similar to those who had taken oral vitamin A.2 As safety data is limited in the pregnant population and with the risk of teratogenicity, the general consensus is to avoid its use in women who are looking to become or are pregnant.
• Salicylic acid: rat studies have shown malformation changes in embryos (cardiac malformations).2 It is considered that salicylic acid should not be the first treatment of choice and, if it was to be used, it should be done so in low concentrations (no more than 2%) for limited durations.2,4
It should be noted that although some of these treatments can be bought over the counter, patients must consult their medical practitioner before starting to confirm the safety of the active ingredients.
Before starting systemic therapy, a discussion of risk versus benefit must be taken with the patient to help decision making. Moderate to severe acne, or acne not responding to the above topical treatments, often requires an addition of oral antibiotics. Erythromycin and clindamycin are again the antibiotics of choice for oral administration in view of their safety.2
The following oral treatments must be avoided:
• Tetracyclines (e.g. doxycycline, minocycline, lymecycline): these are the most common types of antibiotics used in non-pregnant acne suffers. Animal studies have shown teratogenicity and fetotoxicity, including toxic effects on foetal bone and discolouration of teeth.2
• Trimethoprim: another very commonly used antibiotic in non-pregnant acne suffers. A cohort study by Anderson et al. in 2012 highlighted that the use of trimethoprim doubled the rate of miscarriage especially if used in the first trimester.7 There has also been concern of its use in regards to increasing the risk of cardiac defects and oral cleft.2
• Oral retinoids (e.g. isotretinoin): must be avoided at all costs due to the risk of severe teratogenicity (craniofacial, cardiac and thymic malformations).2 This is evident by the pregnancy prevention programme that patients must sign when starting oral isotretinoin, and the advice that they should be using two forms of contraception.
Light-emitting diode (LED) therapy is also safe to use in pregnant patients and is done so in adjunct with other treatments (oral and topical).2,11 LED can treat acne by stimulating collagen formation, decreasing inflammation, shrinking sebaceous glands and killing bacteria:2,11
• Red light therapy penetrates more deeply than blue light, thereby stimulating fibroblast activity and leading to increased collagen production.2,11 It can also modify cytokine activity which decreases local inflammation.2,11
• Blue light therapy is especially effective against P.acnes, as this bacterium produces a porphyrin that is stimulated by the blue light leading to photoexcitation and thereby bacterial destruction.12
Further data on these methods is still required, especially when it comes to the optimal dosing for treatment.
It is extremely vital that we educate all patients on the importance of having a good skincare regime, especially pregnant patients as their options for active treatment are limited. Patients who suffer from acne or who have acne-prone skin should use a light skincare regime, ideally products labelled ‘non-comedogenic’. There are no guarantees that these products won’t cause the skin to break out, but they have been shown to be better suited for this skin type. Non-comedogenic products avoid high comedogenicity acids and their salts, especially isopropyl form (myristic, stearic, palmitic, lauric acid), algae extracts, and foaming agent sodium lauryl sulphate (SLS), thereby lowering the risk of triggering the acne formation cycle.12 There has been a shift to use paraben-free skincare products, in spite of paraben being non-comedogenic. This is because some studies have shown this preservative to be associated with skin damage.13
Patient follow-up is vital and although there is no set guidance on this, I always arrange to see my patients four – six weeks after starting any treatment. The effects of the treatment may only be subtle but it allows for me to review how the patient is tolerating the treatment(s), check adherence and gives the patient an opportunity to ask any questions that they may have. Following this I schedule a follow-up depending on the patient’s severity, but all my patients have an emergency number that they can call so they have full access to the clinic.
There is no concrete timeframe to if/when the skin will clear postpartum, especially if the acne was present prior to the pregnancy. However, as hormone levels and other pregnancy-related changes return to baseline, the skin will likely start to clear. It is important that the skincare regime is continued and active ingredients, such as vitamin A, that could not be used during pregnancy, can be introduced. This is done after a review and another examination of the skin – essentially starting the process from the beginning as a ‘non-pregnant’ patient (taking breastfeeding into consideration).
It is very important to take a good history, perform a detailed examination, review the patient’s general skincare regime and discuss active ingredients in depth. In my opinion, each patient needs to understand their skin, especially in pregnancy as it can be unpredictable, and only then can you start to advise on treatment. Acne treatment in pregnancy should focus on topical preparations, as they have the best safety profile and have the least risk of systemic absorption. Good results can be achieved if applied appropriately and patients adhere to the treatment plans. Nevertheless, we must remember that acne can have a psychological impact on any person and should not be ignored, in spite of the challenges in managing it.
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