Photo by Maureen Noce Photography

Many people struggle with acne at some point in their lives.  The hormonal changes that occur during pregnancy can cause acne to worsen in some women. If they occur, acne flare-ups are often worst during the second or third trimester of pregnancy. There are some acne treatments that women may normally use to control acne that are not safe to take during pregnancy. 

What is Acne?

Acne vulgaris is caused by the interaction of several factors including hormones, dysbiosis (which is an overgrowth of bacteria on the skin), genetics, and diet. The end result is inflammation of the hair follicle and the sebaceous oil producing gland, known as the pilosebaceous unit, and the development of blocked pores known as “comedones”. Closed comedones are considered “whiteheads”, while open blocked pores are considered “blackheads”. Blackheads are darker in color due to oxidization of the oil within the pore. These comedones can then become inflamed and turn into what we recognize as “acne”, which can show up as:

  1. Pustules – pus filled pores that often have a red or pink base 
  2. Papules – red or white raised areas of skin
  3. Nodules – deep in the skin and usually more difficult to treat 
  4. Cysts – pores that have become blocked with keratin from dead skin, bacteria, and sebum

Acne Treatments

Treatment of acne is targeted at the primary underlying cause. The main causes of acne are increased sebum (oil) production, overproduction of the skin protein keratin clogging pores called follicular hyperkeratinization, overgrowth of bacteria called Cutibacterium acnes, increased hormone levels, or inflammation. During pregnancy, acne may flare up due to naturally rising hormone levels in the body, leading to increased sebum production and blocked pores.

Like any other medication or supplement, there are some that are safe in pregnancy and others that are not.  Talk to your physician or your pharmacist if you are pregnant or think you are pregnant before choosing an acne treatment. 

What Treatments ARE Safe?

  1. Salicylic acid (topical, OTC)
    1. Best for: excess sebum production and follicular hyperkeratinisation
    1. Why? While oral acetylsalicylic acid (Aspirin) is generally not recommended during pregnancy, topical salicylic acid does not absorb well so unlikely to pose a risk to the developing fetus.
  2. Benzoyl Peroxide (topical, OTC)
    1. Best for: Bacterial overgrowth/C. acnes proliferation and excess sebum production 
    1. Why? Only 5% of benzoyl peroxide is absorbed into the skin where it is completely metabolized.
  3. Glycolic Acid (topical, OTC brands with “AHA” or “alpha hydroxy acid”)
    1. Best for: excess sebum production and follicular hyperkeratinization
    1. Why? It is a chemical exfoliant that helps to remove dead cells from the surface of skin and exfoliate.  Due to low absorption, it is unlikely to pose a risk to the fetus.  
  4. Azelaic Acid (topical, OTC)
    1. Best for: Excess sebum production, follicular hyperkeratinization, bacterial overgrowth/ C. acnes proliferation. 
    1. Why? It is a chemical exfoliant that helps to remove dead skin cells, exfoliate skin, and remove bacterial from pores.  There is low systemic absorption and unlikely to cause any harm to the fetus.
  5. Topical Antibiotics (clindamycin, erythromycin, available by Rx) 
    1. Best for: Bacterial overgrowth/C. acnes proliferation
    1. Why? Likely safe in pregnancy due to the limited absorption through the skin, and found in clinical trials to be safe for use. Works to decrease detrimental bacterial growth on skin and in pores.  They are often used in conjunction with other topical treatments. 
  6. Oral Antibiotics (erythromycin, available by Rx)
    1. Best for: Bacterial overgrowth/C. acnes proliferation
    1. Why? Erythromycin has been well studied in pregnancy and is likely safe, but topical treatments are always tried first.

What Treatments ARE NOT Safe?

  1. Oral Isotretinoin (Accutane) 
    1. Best for: acne caused by increased sebum production and follicular hyperkeratinisation 
    1. Why not? Isotretinoin is a form of vitamin A that causes severe birth defects including physical and intellectual abnormalities and must NEVER be used during pregnancy.  It should not be used for at least one month before trying to become pregnant. 
  2. Topical Retinoids (Tretinoin – Retin AÒ)
    1. Best for: acne caused by increased sebum production and follicular hyperkeratinization
    1. Why not? The amount of this compound absorbed into the blood through the skin is low but their use remains unsafe due to the risk of birth defects.  More research is needed to be confident they are safe. 
  3. Spironolactone 
    1. Best for: hormonal acne
    1. Why not? It is unsafe in pregnancy due to its effects on the necessary hormone production that occurs for fetal growth. This drug blocks the production of androgen hormones, thereby reducing oil production.
  4. Oral Tetracycline Antibiotics (minocycline, doxycycline, tetracycline)
    1. Best for: acne caused by bacterial overgrowth/dysbiosis
    1. Why not? These are not recommended during pregnancy mainly due to the effects on dental staining and poorly formed tooth enamel in the child.  If taken after 15 weeks of pregnancy the use of these antibiotics may cause discoloration of the baby teeth (but not adult teeth) of the child.  There is also potential for liver toxicity in the mother during the second and third trimester. 
  5. Hormonal Therapies (Oral Contraceptive Pill)
    1. Best for: hormonal acne
    1. Why not? Hormonal birth control options work to regulate female hormones like estrogen and progesterone and will interferes with the normal hormone changes that are necessary during pregnancy.

Most topical over-the-counter treatments are preferred for their safety in pregnancy, while medications that you take orally are generally avoided until after birth and/or breastfeeding.  Talk to your physician or your pharmacist to find a safe product for you while you are pregnant or breastfeeding.  

This post was co-authored by Dana Boe, a third year medical student at the University of Alberta and Dr. Yuliya Koledenko, a family physician with special interest in obstetrical care. 

The post was reviewed and edited by Erin Manchuk, BScPharm, BCGP and Stephanie Liu, MD, MSc, CCFP, BHSc.

References

https://www.acog.org/womens-health/faqs/skin-conditions-during-pregnancy?utm_source=redirect&utm_medium=web&utm_campaign=otn

https://mothertobaby.org/fact-sheets/isotretinoin-accutane-pregnancy/pdf/#:~:text=It%20is%20recommended%20that%20a,days%20after%20the%20last%20dose.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114665/

https://pennstate.pure.elsevier.com/en/publications/the-role-of-follicular-hyperkeratinization-in-acne#:~:text=Follicular%20hyperkeratinization%20is%20a%20key,subsequent%20lesions%20characteristic%20of%20acne.