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[8 min read] Treating acne in pregnancy
Acne vulgaris affects around 85 per cent of Australians at some stage of their lives. Acne is an inflammatory skin condition that can cause significant damage to the skin, ranging from skin congestion to permanent scarring. It is a condition commonly seen in general practice and can greatly affect a patient’s physical, emotional and mental well-being.
Acne can be very challenging to treat, and even more so in patients who are pregnant. Acne appears in around half of all pregnant women, and these patients are unable to use many traditional methods for treating acne such as retinoids and some antibiotics.
Causes of acne
A chronic inflammatory condition, acne 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. The density of this unit is greatest on the face, back and chest, and these are the areas which acne mainly affects. Many patients have more than one affected area.
The pathogenesis of acne vulgaris is thought to involve many complex processes that occur within the skin that exacerbate each other, including:
- Altered follicular keratinocyte proliferation
- Androgen-induced seborrhoea
- Bacterial proliferation (predominantly propionibacterium acnes) within the sebum of hair follicles
- Inflammation of the pilosebaceous unit
Other factors, both intrinsic and extrinsic, play a role in acne’s development, including high levels of androgens, particularly testosterone.
Acne can present as 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 severe cases, inflammatory nodules can develop.
Why is acne common in pregnancy?
Women who have not previously had acne are more likely to develop the condition during pregnancy, usually due to high levels of oestrogen in the first trimester. Women who already had acne when they became pregnant are more likely to develop more severe symptoms.
Hormone changes are the driving force behind the development of acne in pregnancy, especially the increased levels of sex hormones oestrogen and progesterone. Progesterone stimulates the proliferation of the sebaceous glands and increases sebum production, causing an increase in the frequency of acne and the severity of symptoms. In some cases, the increased levels of sex hormones can become semi-permanent and persist after pregnancy.
Consulting pregnant patients
The assessment process for pregnant women is very similar to those who are not pregnant. Practitioners need to establish how long the patient has suffered with acne and what areas of the body are affected; what types of lesions the patient has noticed; which treatments the patient has previously tried; and possible exacerbating factors.
In this context, the main exacerbating factor 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 becoming pregnant; whether they have a family history of acne; whether they have a history of hormonal problems; and if they have changed their diet.
During pregnancy, a woman’s diet may change due to changes in food cravings and associated pregnancy-related conditions. This is particularly common in the first trimester when oestrogen levels spore, potentially resulting in nausea and vomiting.
The most prominent challenges when treating acne in pregnancy are:
- The increased potency of intrinsic hormonal causative factors.
- 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.
As treatment options are greatly limited during pregnancy, it is important to be open with patients about this prior to constructing a treatment plan. 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.
Some patients may want to try as many treatment approaches as possible, as their appearance and the psychological impact of acne may greatly affect them. Other women may prefer more natural treatments or to do nothing at all.
All patients should avoid picking and squeezing their lesions as this can spread bacteria, exacerbate inflammation and cause scarring. Patients should also use gentle skin care products that contain mostly natural ingredients, as over cleansing the skin can trigger an excess production of sebum. Patients should use oil-free make-up and avoid products that are heavy on the skin’s surface. They should also ensure their skin is adequately hydrated and that they consume a healthy, balanced diet.
Many agree that topical treatments are the safest way to treat pregnant patients who are experiencing acne. 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. Oral antibiotics that are safe to prescribe in moderate and severe cases include penicillin, erythromycin and cephalosporins.
Treatments to avoid
The safety of using aesthetic treatments such as laser therapy, radiofrequency and chemical peels to address acne in pregnancy is uncertain, and so should be avoided. Treatments to absolutely avoid are topical retinoids such as tretinoin, topical isotretinoin and adapalene, as well as high concentrations of salicylic acid (patient dependent).
Oral antibiotics to avoid include:
- Tetracyclines, such as doxycycline, minocycline and lymecycline
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.