Part I, The Drugs

There's nothing like having a baby to bring a smile to your face. But what will pregnancy do to your skin? Who hasn't heard how pregnancy is supposed to make one's skin glow? Well, whoever said it must have missed out on the acne flares, the blotchy facial discoloration, and the itchy rashes, not to mention those stretch marks! And that doesn't even begin to cover all the concerns over what can and can't be used during pregnancy. Here's what every pregnant woman needs to know about babying her skin during this special time.

Do You Or Don't You?

For medical-legal issues, most doctors will advise their healthy pregnant or nursing patients as well as those contemplating pregnancy to avoid all medications except prenatal vitamins and possibly some iron and calcium supplements. The unfortunate truth is that doctors simply do not know if all medications cause concern for pregnant patients. A lack of testing by drug companies (for obvious reasons) and a paucity of data hinder the ability of the doctor to help guide the patient. Much of what we know comes from patients who have either used the medication due to health concerns that outweighed the risk of medication use, as well as a retrospective look at the positive or harmful effects that various products have had upon pregnancy.

A pregnancy purist is one who wishes to skip the use of any drug (whether rx or OTC). But if you think that all pregnant women actively avoid the use of all medication during pregnancy, think again. According to a report by CNN in December of 2000, sixty percent of women used at least one prescription drug, at some point in pregnancy.

There are more than 6 million pregnant women a year in the United States. Almost all of them used at least one OTC medication during their pregnancy. And fifty seven percent used herbal remedies, which have even less pregnancy safety information than FDA regulated drugs.

With these statistics in mind, how can an intelligent, informed decision be made? First it is important to understand how prescription medications are classified for their effects upon a pregnancy. The FDA requires drug labeling of prescription medications to include information on a drug's ability to cause birth defects and other effects on reproduction and pregnancy. Drugs must also be classified under one of five letter categories: A, B, C, D, and X.

A: Controlled Studies Show No Risk. Adequate, well-controlled studies in pregnant women have not shown an increased risk to the fetus at any point during pregnancy.

B: No Evidence Of Risk In Humans. Adequate, well-controlled studies in pregnant women have not shown any increased risk of fetal abnormalities despite adverse findings in animals.

or
In the absence of adequate human studies, animal studies show no increased fetal risk. The chance of fetal harm is possible but remote.

C: Risk Cannot Be Ruled Out. Adequate, well-controlled human studies are unavailable and animal studies have shown a risk to the fetus or are also lacking. There is a chance of fetal harm if the drug is given during pregnancy but the potential benefits outweight the potential harm.

D: Positive Evidence Of Risk. Studies, adequate well-controlled or observational, or post-marketing, in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk such as in life-threatening situations.

X: Contraindicated In Pregnancy. Studies, adequate well-controlled or observational, or post-marketing reports in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. The use of the product is contraindicated in women who are or may become pregnant.

Next, the stage of pregnancy also can influence clinical decisions. Since half of all those 6 million U.S. pregnancies are unplanned, timing is everything. Tetracycline, and its variants are frequently used to treat acne. While the use of tetracycline is contraindicated during pregnancy, problems such as permanently stained teeth are not of concern until well after the 11th week. By then, pregnancy is typically realized and discontinuing the medication is all that is necessary. However, Accutane has a high rate of causing birth defects. The concern for the formation of fetal heart anomalies and abnormal growth of the head and face creates the need for 2 methods of reliable contraception while on this medication.

Finally, medication is not prescribed in a void. The risk vs. benefits to a pregnant woman must be taken into consideration. Heart conditions, high blood pressure, diabetes, etc., have to be addressed for the health of both mother and child.

Commonly used OTC ingredients are a major concern for pregnant women. All too often home use products include a bevy of FDA OTC drug ingredients and contain little information on their safety. Most medications found in over-the-counter (OTC) use are considered safe to use during pregnancy particularly when used in small amounts over a limited time frame. Although many medicines can pass into breast milk in small amounts, the majority of them may be used safely while breast-feeding. When breast-feeding is specified, it refers to the medication making its way into breast milk, not related to use on the skin of the breast that might come into contact with the baby.

I have managed to put together a list of many of these based upon information derived from Medline Plus, a service of the NIH and the U.S. National Libraries of Medicine, and the Physician Desk Reference (PDR). It is always recommended to share the use of medication, whether OTC and prescription as well as skincare selections with your obstetrician.

• Alcohol and Acetone Topical

  Think nail polish remover, antibacterial wipes, etc.

  Pregnancy: No reports of birth defects or other concerns in human use with this topical combination.

  Breast feeding: No reports of problems in nursing infants.

• Anesthetics Topical & Local

  Think products to soothe itching, sunburn, bug bites and locally injected anesthetics.

  This category includes: Benzocaine, Benzocaine and Menthol, Butamben, Dibucaine, Lidocaine, Pramoxine, Pramoxine and Menthol, Tetracaine, Tetracaine and Menthol.

  Think PrameGel, Prax Lotion, LMX 4% Topical Anesthetic Cream - 30gm, etc.

  Pregnancy: Studies haven't been performed in pregnant humans but there have have been no reports of problems in pregnant patients. In animal studies, lidocaine has not caused birth defects or other problems. Animal studies have not been performed on the other topical anesthetics.

  Breast Feeding: Topical anesthetics have not been reported to cause problems in nursing infants.

• Antibiotic Ointments

  This category includes triple antibiotic ointment, as well as Polysporin First Aid Antibiotic Ointment, Neosporin and Bacitracin.

  Pregnancy: No studies performed in pregnant women, but no known birth defects or other problems seen in humans.

  Breast-Feeding: It is not known if these topicals are present in breast milk, but no reports exist of problems with nursing infants.

• Antihistamines

  Mainly oral itch relief, although topical benadryl certainly falls into this category as well.

  Pregnancy: Hydroxyzine (brand name Atarax) is not recommended for use in the first trimester of pregnancy. Has been shown to cause birth defects in animal studies if given in doses much higher than normal human use.

  Azatadine, brompheniramine, cetirizine, chlorpheniramine, clemastine, cyproheptadine, dexchlorpheniramine, dimenhydrinate, diphenhydramine (brand name Zyrtec), doxylamine, loratadine (brand name Claritin), and tripelennamine: No studies in pregnant women have been performed, but no known causes of birth defects or other concerns have been demonstrated in animal studies. Guidelines vary by drug manufacturer in this category.

  Desloratadine and fexofenadine: No studies in pregnant women performed. But animal studies show birth defects or other concerns exist when doses given that are much larger than typical human patient dosing. Discuss these medications with your physician.

  Breast Feeding: Antihistamines can be found in breast milk in small concentrations. Use is not typically recommended since sedation, irritability or hyperactivity can result in babies. Antihistamine use can also result in a reduction of breast milk flow in some patients.

• Benzoyl Peroxide

  Primarily used for acne relief, benzoyl peroxide comes in a variety of strengths and combinations with other active ingredients. Discuss the rare dab to a pimple with your physician.

  Pregnancy: No studies on humans or animals have been performed. Benzoyl peroxide can be absorbed through the skin.

  Breast-feeding: Benzoyl peroxide may be absorbed through the mother's skin. The presence of benzoyl peroxide in breast milk is unknown. However, reports of problems in nursing babies exist.

• Capsaicin

  Used in pain management such as in the relief of post herpetic neuralgia. Can be found in Zostrix HP Cream.

  Pregnancy: No reports of birth defects or other concerns in human use.

  Breast Feeding: Unknown if Capsaicin can be passed through breast milk. No reports of problems with nursing infants. It is important to remember that topical use of this medication in an area coming into contact with the nursing infant should be avoided to spare the baby severe skin irritation.

• Coal Tar

  Usually an ingredient used in dandruff and psoriasis shampoos as well as topical psoriasis treatment products. Due to its effect upon reducing or stopping cellular turnover, it's probably wise to skip this during pregnancy.

  Pregnancy: No human or animal studies performed.

  Breast-feeding: Unknown if this topical can be present in breast milk. No reports of problems in nursing infants.

• Hydrocortisone

  Used to treat skin irritation and inflammation. OTC versions include one half and one percent of the active ingredient. Found in such products as Cortaid 1% Hydrocortisone Anti-Itch Cream.

  Pregnancy: Used under proper controlled situations, hydrocortisone has not been shown to cause problems. No studies in pregnancy have been performed. Birth defects have occurred in animal studies using large amounts or prolonged use of topical corticosteroids.

  Breast feeding: No reports of problems in nursing infants.

• Nystatin

  A treatment for candida yeast of the skin.

  Pregnancy: No reports of birth defects or other problems in pregnant humans.

  Breast-feeding: It is not known whether nystatin passes into breast milk. No reports of problems with nursing infants.

• Miconazole

  Treats yeast and some fungal infections of the skin.

  Pregnancy: Topical miconazole preparations have not been shown to cause birth defects or other problems in humans.

  Breast feeding: No reports of problems with topical Miconazole causing problems for nursing infants.

• Minoxidil

  Used topically in the treatment and prevention of hair loss. Commonly known under the brand name Rogaine.

  Pregnancy: No studies in pregnant women. But, some studies in animals have shown that oral minoxidil, can causes problems during pregnancy, (these concerns do not include birth defects). Recommended not to use if pregnant or nursing.

  Breast Feeding: The presence of topically applied minoxidil in breast milk is unknown. However, oral minoxidil can be found in breast milk. Minoxidil is not recommended during breast-feeding as it may cause problems in nursing infants.

• Permethrin

  Both one and five percent fall into this category. One percent is found in home lice treatments including Nix Lice Treatment Creme Rinse. Five percent is found in prescription strength Elimite for scabies treatment.

  Pregnancy: No studies in pregnant women. Animal studies have not shown birth defects or other concerns.

  Breast Feeding: Unknown if premethrin can be found in breast milk. However, animal studies have shown that permethrin can cause tumors. Skip it unless you discuss with your doctor and have good reason for use.

• Pyrithione Zinc

  A favorite in dandruff shampoos and treatment soaps for Seborrheic dermatitis (DHS Zinc Shampoo) and used in tinea veriscolor therapy (ZNP Bar).

  Pregnancy: No reports of birth defects or other problems in pregnant women.

  Breast feeding: Unknown if present in breast milk. Pyrithione has not been reported to cause problems in nursing infants.

• Resorcinol

  While often thought of as an ingredient in certain chemical peels, this agent is often combined with sulfur such as in Rezamid Acne Treatment Lotion.

  Pregnancy: Resorcinol may be absorbed through the mother's skin. However, topical resorcinol and sulfur combination has not been shown to cause birth defects or other problems in humans.

  Breast Feeding: Resorcinol may be absorbed through the mother's skin. However, a topical resorcinol and sulfur combination has not been reported to cause problems in nursing babies.

• Salicylic Acid

  Trendily termed a BHA, salicylic acid applied on large areas or in high concentrations may be of concern whether used for skin rejuvenation, acne treatment or corn and wart relief.

  Pregnancy: Salicylic acid is capable of being absorbed through the skin. No studies exist on pregnant women. Animal studies show birth defects when given systemically in doses 6 times those recommended in topical use for human patients. Discuss with your physician particularly if large areas of the body are to be treated.

  Breast Feeding: Absorbed through mother's skin. However, no reports of problems caused for nursing infants.

• Selenium Sulfide

  Often included in dandruff shampoos or found in Selsun Blue shampoo for tinea veriscolor therapy.

  Pregnancy:
  Scalp Use: No reports of birth defects or other concerns in human use.

  Body Use: Selenium sulfide can be absorbed through the skin when applied in a widespread manner. It is not recommended for this use while pregnant.

  Breast feeding: No reports of problems in nursing infants.

• Sulfur

  Pregnancy: Not been shown to cause birth defects or other concerns in humans.

  Breast feeding: No reports of problems for nursing infants.

• Terbinafine

  An antifungal active ingredient found in the brand Lamisil AT.

  Pregnancy: No studies in pregnant women. No reports of birth defects or other concerns in animal studies.

  Breast Feeding: Oral terbinafine passes into breast milk. Unknown if topically applied terbinafine can pass into breast milk. Do not apply to the breast if nursing.

• Sunscreen

  This category includes 64 ingredients or combination of ingredients used as active ingredients in sunscreen. Certainly with an increase risk of developing melanoma during pregnancy as well as cosmetic concerns of melasma, the use of sunscreen to help prevent sun damage and resulting future skin cancer appears to far outweigh any unknown risks at this time.

  Pregnancy: Studies lacking on pregnant women and animals.

  Breast Feeding: There are no reports of problems with sunscreen use affecting breast milk and nursing infants.

There are other controversial or hot topics related to products and ingredients and their safety for use during pregnancy that I'd like to address in more detail.

Vitamin A

The use of topical vitamin A containing medications and skincare products during pregnancy and nursing is NOT recommended. Not only does this include prescription treatments Avita, Avage, Differin, Retin A, Renova and Tazorac but any OTC retinol or retinyl palmitate containing product as well. Generic names for the prescription meds include Adapalene, tretinoin and Tazarotene.

Oral use of large amounts of Vitamin A and it's derivatives, like Accutane, are known to cause birth defects. While this theory was extrapolated on to topical vitamin A creams like Retin A (as it was one of the original products available), to my knowledge, there have been no known birth defects from the accidental use of Retin A during pregnancy throughout the 20 plus years of it's use. That has sparked some controversy regarding whether women should truly avoid it, but for safety's sake it is still considered prudent to avoid the use of all topical vitamin A products during pregnancy as well as during nursing. Let's face it, nothing is as important as the health of your baby, so it's worth the wait.

Depilatories

The use of hair removal products during pregnancy can be of concern. Depilatories work by by breaking the disulfide bonds in hair, which results in the hair being broken off bluntly at the follicular opening. Both active ingredients found in depilatories fall into category C (safety for use during pregnancy has not been established).

Depilatories include barium sulfide powder of about 2% strength and calcium thioglycolate. The thioglycolate produces a mercaptan odor often masked with fragrance. In rare cases this fragrance can cause an allergic reaction. Chemical burns can result with either formulation if left on too long. Due to the chemical nature of these ingredients and potential systemic absorption through the skin, hair follicles or from the fumes, it is probably best to avoid their use while pregnant or nursing.

Hair Dye

Since most studies have not focused solely on determining the risk of hair dye use during pregnancy, it remains somewhat controversial as to the realistic risks faced by a pregnant patient craving hair color. Hair dyes contain a variety of ingredients that when ingested fall into the poisonous category.

Permanent hair dyes may contain naphtylamine, phenylene diamines, toluene diamines. Temporary dyes may contain silver, mercury, lead, arsenic, bismuth and pyrogallol. Other concerning ingredients may also be present. Because of side effects these ingredients can cause, the rule of thumb is to avoid hair color during pregnancy. Hair stains that are not applied to the scalp itself may in some cases be fine to pursue.

Please read on to Part 2 of Pregnancy and Your Skin for information on the skin concerns common during this time.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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