WHEN THE PATIENT IS PREGNANT Which medications and procedures are safe for pregnant patients? Valerie Hanft, MD, answers questions about pregnancy- related skin issues, cosmetic procedures and over-the-counter drugs, and reviews the FDA pregnancy safety ratings for common dermatology medications.

ELLEN MEYER, MANAGING EDITOR

ustin, TX, dermatologist Valerie may be limited by the safety rating of she does not hesitate to perform a Hanft has spoken frequently the appropriate medications. biopsy during pregnancy, just as she Aon the topic of drug consider - Growths. Pregnancy hormones stimu - would otherwise. ations for pregnant patients, with the late many kinds of growths, notes Dr. Rashes, Changes in Acne. There are also growing baby’s health uppermost in Hanft. “Most commonly, we see in - a number of pregnancy-associated rashes. mind. “The general rule is for the creases in acrochordons , angiomas , nevi Among them, she calls pruritic urticarial pregnant woman to speak first with and warts .” She adds, “As pregnancy is papules and plaques of pregnancy her obstetrician and make a treatment also a mild state of immunosuppression, (PUPPP) the “classic example.” Many of decision based on weighing the risk warts can be more numerous or more these rashes can be managed with judicious against the benefits.” difficult to treat. During pregnancy, we use of topical steroids and antihistamines. rely on liquid nitrogen therapy or elec - In addition, she says other pre-existing WHAT SKIN ISSUES ARE SPECIFICALLY ASSOCIATED trocautery and prefer to avoid chemical skin conditions may change in severity. WITH PREGNANCY? treatment modalities.” “Common eczema rashes seem to worsen Many skin issues associated with As for the moles, she explains, “Many or increase in frequency during pregnancy, pregnancy, maintains Dr. Hanft, are not women notice not only more moles, and patients will report unpredictable preventable and treatment for these new but that some grow in size or darken.” changes in their acne, which can worsen conditions, as well as pre-existing ones, If the changes in moles are concerning, or even clear entirely.”

42 MAY 2010 | SKIN & A GING | www.skinandaging.com CURRENT CATEGORIES FOR DRUG USE IN PREGNANCY Category Description A Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities B Animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and well-controlled studies in pregnant women. or Animal studies have shown an adverse effect, but adequate and well- controlled studies in pregnant women have failed to demonstrate a risk to the fetus. C Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women. or No animal studies have been conducted and there are no adequate and well- controlled studies in pregnant women. D Studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. X Studies, adequate well-controlled or observational, 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.

such as titanium dioxide and zinc oxide, and Category A — The few drugs that are says that the estrogenic effects of soy can included in this category — folic acid and worsen those dark patches. levothyroxine — have been on the market “Pregnant patients should be extra cau - for many years and have been used in a tious around children with viral exanthems large number of pregnant women. as some can have serious sequelae should Category B — These drugs are generally the mother become infected. In addition, considered safe but not as definitively as I recommend the inactivated flu vaccine — those in group A. They include drugs — not nasal spray — but many other vaccines such as antibiotics (penicillin, erythromy - are contraindicated,” warns Dr. Hanft. cin) and antihistamines — not studied in Also, women with a history of genital her - humans for which animal studies showed pes should be reminded to make their ob - no risk or drugs for which animal studies stetricians aware of it to avoid transmission showed risk, but human studies did not. to the newborn during delivery. Category C — Dr. Hanft calls this the big gray zone, due to inadequate data in WHICH DERMATOLOGY-RELATED DRUGS CAN BE humans. It includes drugs for which ani - Melasma. Melasma, or the mask of preg - SAFELY USED DURING PREGNANCY? mal studies may have been positive or nancy, is one of the most frequently re - Many acne/rosacea medications are negative for fetal risk, and no human stud - ported pregnancy-related complaints, not recommended during pregnancy. ies have been done. Among them are oral second only to stretch marks. It is especially There are a few, however, that can be and topical steroidal anti-inflammatory common among those with dark skin, and used without concern, namely those in drugs; benzoyl peroxide and retinoids, as it may persist after the delivery. Category A in the FDA use-in- well as the quinolone group, which in - pregnancy ratings, a set of guidelines in - cludes ciprofloxacin, the antibiotic WHAT CAN BE DONE TO PREVENT THESE troduced in 1979 that established safety trimethoprim/ sulfamethoxazole (Septra), CONDITIONS AND OTHER CONDITIONS? profiles that defined the risks for fetal in - and some antifungals including flucana - While most of the pregnancy-associated jury caused by pharmaceutical agents zole, ketoconazole and itraconazole. lesions and dermatoses, she states, are not used in the United States. ( See Table.) Category D — For these drugs, data in preventable, for those that can be limited Note that they are not intended to de - human studies have shown risk, but their or their risk of contraction reduced, she of - lineate the risks to nursing infants. use may be justified. It includes tetracy - fers these suggestions. Dr. Hanft discusses these categories, not - cline, which can cause fetal tooth discol - To limit melasma, or chloasma, Dr. Hanft ing that the use of some in all but Category oration and skeletal abnormalities in the stresses the importance of meticulous sun X may be justified, depending on the sever - fetus and hepatotoxicity or fatty livers in protection. She prefers physical sunscreens, ity of a condition and stage of pregnancy. mothers. It also includes the antifungal

MAY 2010 | SKIN & A GING | www.skinandaging.com 43 WHEN THE PATIENT IS PREGNANT

potassium iodide, which can affect thy - SAFEST TREATMENTS FOR DERMATOLOGICAL DISORDERS DURING PREGNANCY roid function and cause goiters in the Disease Medication Name developing fetus. Acne Topical clindamycin, erythromycin Category X — Dr. Hanft terms these drugs — isotretinoin, thalidomide, Rosacea Metronidazole, azelaic acid methotrexate, topical 5-fluorouracil — Psoriasis Topical steroids (sparingly), phototherapy “absolutely contraindicated,” as “in these drugs, fetal risk clearly outweighs any pos - Dermatitis Topical steroids (sparingly), loratidine or diphenhydramine sible benefit for the patient.” In addition to isotretinoin and thalidomide, many Genital human Liquid nitrogen chemotherapeutic drugs are rated X. These papillomavirus include methotrexate. infection Herpes simplex Acyclovir HOW ARE RISKS AND BENEFITS CONSIDERED virus infection DURING PREGNANCY? Fungal infections Topical antifungals Again, saying that the obstetrician Bacterial Penicillins, cephalosporins, azithromycin should be consulted on drugs being con - infections sidered in categories B to D, Dr. Hanft explains that pregnancy stage can be the gory chain when possible, offering the conceive. Isotretinoin must be stopped at deciding factor. following recommendations. least 1 month prior. Early pregnancy. The primary concern Acne. Topical therapy is preferred for the with safety relates to organogenesis in the treatment of acne during pregnancy. From WHAT COSMETIC PROCEDURES CAN BE SAFELY first and second trimesters, especially from Category B, a few options are topical UNDERTAKEN DURING PREGNANCY? the fifth week, when placental circulation metronidazole, topical azelaic acid, clin - “Aside from microdermabrasions and is established, through the third month, damycin and — except in its estolate form facials, I do not recommend cosmetic pro - when organogenesis is presumably com - in the third trimester — oral erythromycin. cedures as a general rule. The majority of plete. “The physician has the most freedom Psoriasis. Phototherapy is considered cosmetic procedures have not been studied to prescribe drugs in the B, C, and if, ab - the safest therapy for extensive psoriasis in the pregnant or lactating patient. And, solutely necessary, D categories during the during pregnancy. From Category B, should a patient have a complication, treat - second trimester after the structures are loratidine and diphenhydramine are best- ment options are often be limited. For ex - formed but before issues of gestation, labor choice antihistamines. Topical corticos - ample, if the patient experiences any and hemorrhage come into play.” teroids and topical calcineurin inhibitors hyperpigmentation after laser hair removal, Late pregnancy. Some over-the-counter tacrolimus and pimecrolimus are Category hydroquinone should not be used.” drugs, most notably the NSAIDs, must be C and should be used judiciously. avoided during the third trimester. “For ex - Viral Infections. For the treatment of A WORD ABOUT THE CATEGORIES ample, most problems with aspirin are asso - genital warts, physical modalities such as Although Dr. Hanft made it clear that she ciated with the third trimester, including cryotherapy are felt to be safe in pregnancy. generally considers pregnancy no time to premature closure of the patent ductus ar - Acyclovir, famciclovir and valacyclovir are trade benefits for risks, she states her belief teriosus, which compromises fetal circula - all pregnancy Category B. — shared by many of her colleagues — that tion. Aspirin can also influence the duration Fungal Infections. From Category B is the pregnancy category might overstate the of gestation and labor, thereby contributing oral terbinafine. From Category C are flu - risk for some of the medications dermatol - to post maturity,” says Dr. Hanft. conazole and itraconazole, but most der - ogists depend upon. This, she says, is partic - From the Category B antibiotics and matologists limit these medications to ularly the case with medications available in antihistamines, the estolate form of topical use. both topical and systemic forms. “Systemic erythromycin cannot be prescribed due Bacterial Infections. Penicillins, steroids are known to cause cleft palate in to hepatoxicity concerns in the mother, cephalosporins and azithromycin are all mice and possibly low birth weight and hy - and diphenhydramine is contraindicated pregnancy Category B and are generally poadrenalism in humans, while when topi - during the last few weeks of pregnancy considered safe in pregnancy. cal steroids are used on a limited area for a because of reports that it can cause defined period of time, their risk is consid - retrolental fibroplasia. AT WHICH POINT DO YOU RECOMMEND PATIENTS ered minimal,” points out Dr. Hanft. “Sim - DISCONTINUE ANY QUESTIONABLE DRUGS? ilarly, it is widely believed that tretinoin’s C WHAT DO YOU CONSIDER ‘BEST PRACTICES’ FOR Dr. Hanft says she recommends that category has more to do with the devastat - SKIN CONDITIONS DURING PREGNANCY? Category C and D drugs be discontinued ing risk of birth defects associated with oral Dr. Hanft stresses the importance of — although topical steroids may be used isotretinoin than isolated reports linking always prescribing higher on the cate - sparingly — when patients are trying to topical use to ear malformations.” I

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