Acne During Pregnancy: What You Need to Know
Acne is common during pregnancy, but its course and severity can be unpredictable. Some women may see their acne improve, while others might experience worsening symptoms or develop acne for the first time. Treating acne during pregnancy can be challenging since only certain medications and procedures are safe to use.
The FDA classifies medications into five safety categories:
Category A: No risk to the fetus in any trimester, based on well-controlled studies in pregnant women.
Category B: Animal studies show no risk to the fetus, but there are no adequate studies in pregnant women.
Category C: Animal studies show adverse effects, but there are no adequate human studies. The drug may be used if the potential benefits outweigh the risks.
Category D: There is evidence of fetal risk based on human studies, but the drug may still be used if the benefits outweigh the risks.
Category X: Studies show fetal abnormalities or evidence of fetal risk, and the drug's risks outweigh any potential benefits.
During pregnancy, only medications from Categories A, B, and sometimes C are considered safe. Personally, I only recommend Category A or B medications. However, as of March 2014, there are no Category A medications for treating acne during pregnancy. This leaves us with the following Category B options:
Topical Anti-Acne Products Safe for Use in Pregnancy:
Clindamycin phosphate (e.g., Dalacin T™)
Erythromycin (e.g., Ilotycin T.S.™)
Azelaic Acid (e.g., Skinoren™)
Benzoyl peroxide gel and wash (e.g., Benzac AC 5™) - Category C, not recommended.
Topical glycolic acid and salicylic acid - Not categorized by the FDA, so not recommended.
First-Line Oral Anti-Acne Medications Safe for Use in Pregnancy:
Cephalosporins (e.g., Cephalexin 500mg PO twice daily)
Amoxicillin (250mg-500mg twice daily) - Not recommended in the first trimester.
Second-Line Oral Anti-Acne Medications Safe for Use in Pregnancy:
Azithromycin (500mg on Monday, Wednesday, and Friday)
Erythromycin stearate (not Erythromycin estolate or Erythromycin ethylsuccinate) - 250mg-500mg 2-4 times daily - Not recommended in the first trimester.
Third-Line Oral Anti-Acne Medication Safe for Use in Pregnancy:
Clindamycin (75mg-150mg twice daily)
Anti-Acne Procedures Safe for Use in Pregnancy:
Red light therapy
Intense Pulsed Light therapy
Skin needling
Pulsed-dye laser therapy
Photodynamic therapy with Aminolevulinic acid (ALA) has been reported in the literature, but since ALA is a Category C drug, I do not recommend it. Narrowband (311nm) UVB light therapy is also mentioned in the literature, but I avoid it due to the risk of reduced folic acid levels with prolonged UVB exposure.
For very mild cases of acne during pregnancy, I typically start with Clindamycin phosphate, with or without Azelaic Acid, combined with a sebum-reducing face wash.
More severe cases might require an oral antibiotic like Amoxicillin or Cephalexin. If a patient is allergic to these or if the acne is unresponsive, Azithromycin or Erythromycin stearate may be the next options. Clindamycin can be used in rare cases where none of the previous antibiotics are suitable.
The only safe form of Erythromycin during pregnancy is Erythromycin stearate. Erythromycin estolate causes reversible liver toxicity in 10% of patients, and Erythromycin ethylsuccinate can cause fetal heart defects if used in the first trimester. To avoid accidental dispensing mistakes, it’s best to avoid all forms of Erythromycin during the first trimester.
For the most severe cases of acne in pregnancy, I recommend combining a topical product with an oral antibiotic and skin needling. Skin needling also has the added benefit of improving skin texture and reducing acne scarring.
Treating acne during pregnancy is challenging. No medication is 100% safe, and even those with no known fetal risks can still cause reactions in the mother that might affect the pregnancy.
While acne during pregnancy can be treated successfully, it’s crucial to carefully weigh the pros and cons of each treatment option.
