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PEER REVIEWED FEATURE 2 CPD POINTS Managing the skin in Part 2. Pre-existing, new and postpartum skin conditions NINA WINES BSc, MB BS, DRANZCOG, FACD Management of pre-existing skin conditions, such as , and atopic eczema, and new KEY POINTS conditions such as skin cancer may need to be modified during pregnancy, when many of the • Pregnancy has an unpredictable effect on pre-existing skin conditions such as acne, psoriasis and atopic usual treatments are contraindicated. Management eczema; options exist for treatment during pregnancy, but of postpartum and problems can be optimising control before conception is recommended. helped by a simplified diagnostic approach and • Surgical procedures are best performed in the second knowledge of safety during trimester or delayed until after the birth if possible. . • Management of certain types of new is not necessarily altered by pregnancy. regnancy has unpredictable effects on pre-existing skin • In pregnant women with superficial nonurgent such as acne, psoriasis and atopic eczema, and nonmelanoma skin cancer, monitoring the cancer and increases the need for caution in treatment because of postponing treatment until after the birth may be the need to consider medication safety for the as considered in some cases. • Management of postpartum nipple and breast problems Pwell as the . GPs are at the forefront of managing these can be helped by a simplified diagnostic approach and a problems. Many drugs are contraindicated during ­pregnancy confident understanding of the safety of skin and , and should be ceased before conception. However, during breastfeeding. options exist for treating pregnant women with these skin ­conditions. In ­addition, as growing numbers of women have children in their 30s and 40s, the need to manage melanoma and non­melanoma skin cancer (NMSC) in pregnancy is increasing. Postpartum, many women present to their GPs with problems of the nipple, or breast during breast- MedicineToday 2016; 17(9): 27-35 feeding. Other ­common postpartum concerns include sagging abdominal or breast tissue and unsightly, painful or itchy Dr Wines is Principal Consultant Dermatologist at Northern Sydney BARTEK TOMCZYK/ISTOCKPHOTO

© caesarean scars. ; and a Visiting Medical Officer at The Skin Hospital, Sydney, NSW.

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Psoriasis Pregnancy has a variable effect on psoriasis, causing improvement in about 50% of women, worsening in 20% and no change in 20%. About 65% of women with psoriasis experience a flare after delivery.4 Optimising control of the condition before conception is desirable. Women (and men) planning a preg- nancy should cease three months before conception. Women should cease acitretin two years before conception; in fact, acitretin should be avoided by Figures 1a and b. Acne during pregnancy. a (left). A patient with acne and during the women of child-bearing age unless there first trimester of pregnancy. Before the pregnancy she had almost no acne and had not are no alternatives.3 Biologic drugs should received acne treatments. During the pregnancy, she was treated with antibiotics and topical . b (right). The same patient four weeks after the birth, showing clearing of the acne. be ceased at least six months before ­conception (, infliximab and ustekinumab) or one month before con- This is the second in a two-part series recommended as baseline therapy.2 Slow ception (etanercept). There is no need to on managing skin ­conditions during preg- introduction of benzoyl peroxide with a terminate the pregnancy if a nancy. Part 1 focused on the management moisturiser every second day helps reduce becomes pregnant while taking a biologic, of pregnancy-related skin diseases (pub- irritation and improve compliance. Always but cessation of treatment and referral to lished in the July 2016 issue of Medicine remember to inform the patient that this an experienced obstetrician and derma- Today).1 This article outlines the manage- product can bleach clothing and sheets. A tologist is warranted. ment of pre-­existing skin diseases and skin combination of topical or There are several options for treatment cancers that develop during pregnancy as clindamycin with benzoyl peroxide is best of psoriasis during pregnancy. Moisturising well as postpartum skin problems. for inflammatory acne.2 Topical and oral creams help to reduce itch. Topical corti- antibiotics should not be used as mono- costeroids and analogues are Management of pre-existing therapy but combined with topical benzoyl relatively safe, but women should avoid skin diseases in pregnancy peroxide to decrease bacterial resistance.2 using large quantities for long periods.4 Pregnancy can have unpredictable effects Topical salicylic acid is considered safe in Ultraviolet B (UVB) light therapy is also on pre-existing skin disorders. These effects pregnancy, given that low-dose aspirin is safe during pregnancy, although cumula- are mainly caused by changes to the used to treat pre- in pregnant tive UVB treatment reduces folic acid levels, immune system to prevent fetal rejection. women.2 It should be used at a low concen- and folic acid supplementation is therefore tration (e.g. 2%) and over a limited body recommended during treatment.5 Topical Acne surface area. tar, and pimecrolimus are not It is not uncommon for acne to worsen in For moderate-to-severe acne, oral eryth- recommended d­ uring pregnancy.3 Most early pregnancy and then to improve as the romycin or is safe for a few weeks. systemic medications (methotrexate, pregnancy progresses (Figures 1a and b).1 After the first trimester, nodulocystic or ­acitretin, mycophenolate mofetil) are Patients with acne who are planning a preg- scarring acne can be managed in most cases ­contraindicated in pregnancy. nancy should be advised to optimise acne with oral 0.5 mg/kg combined When all other options are ineffective control before conception. Topical with a systemic antibiotic, in collaboration or impractical, referral to a dermatologist (adapalene, and isotretinoin), oral with a dermatologist and obstetrician when for consideration of treatment with oral tetracyclines and oral isotretinoin are possible. corticosteroids, immunomodulatory or contraindicated in pregnancy.2,3 Over-the-counter washes and moistur- biologic treatment is recommended. In When assessing acne it is helpful to isers containing salicylic acid or glycolic rare cases of very severe psoriasis in preg- grade the severity (mild, moderate or acid are generally considered safe, are well nancy, the balance of evidence suggests severe) and assess the psychological impact tolerated and complement treatment.2,3 that the use of tumour necrosis factor alpha on the patient. For mild acne during preg- Pre-treatment photos (front, oblique left inhibitor biologics (etanercept, adali- nancy, commence topical therapy. Topical and right views) are useful to monitor mumab and infliximab) is acceptable or benzoyl peroxide are progress. when other options have been ineffective

28 MedicineToday ❙ SEPTEMBER 2016, VOLUME 17, NUMBER 9 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. and the benefit outweighs the risk.4,6 Infliximab can be detected in the for up to six months after delivery. It is very important not to administer live ­vaccines to the mother or infant for up to seven months postpartum if the mother has received biologic therapy during pregnancy.4

Atopic and eczema Eczema is the most common dermatosis of pregnancy. Eczema in pregnancy is now Figures 2a and b. a (left). Hypertrophic scar following excision of a basal cell carcinoma during termed ‘atopic eruption of pregnancy’, and pregnancy. b (right). The scar three years postpartum, after treatment with intralesional was covered in Part 1 of this series. Preg- corticosteroids. nancy has a variable effect on eczema; in 25% of patients the eczema improves but range of disorders such as migraine, Skin surgery in more than 50% it worsens. Pre-existing ­dystonia, sweating disorders, spasticity Ultimately, the decision about surgical eczema may deteriorate at any stage of the and pain, there are few data on its effects treatment of a skin concern such as a pregnancy, especially during the second on the pregnant woman and the fetus.8 changing mole or skin cancer during preg- ­trimester. In 10% of cases it flares in the Botulinum toxin has a high molecular nancy must balance the appropriate level .7 weight and is unlikely to cross the pla- of concern for the safety and protection of Advice for women with eczema plan- centa. ­Nevertheless, use of ­botulinum the mother and the fetus. Nonurgent sur- ning pregnancy should include strategies toxin for cosmetic purposes is not gery is best performed in the second tri- to minimise activity at baseline ­recommended during pregnancy. There mester or after delivery. Lignocaine does including: are also no ­precise data on how long to not cross the , and the small • avoiding irritants and allergens postpone ­conception after botulinum amount of required for skin • encouraging the use of emollients toxin i­njections. In my practice, I advise procedures is unlikely to be a concern.3,10 • optimising topical treatment. waiting until the effect of the toxin has For surgical procedures performed after Women who are receiving systemic completely worn off (usually four the beginning of the second trimester, posi- treatment for eczema should be informed months) before trying to conceive. It is tion the patient in the left lateral tilt of the minimum time interval between unknown whether botulinum toxin with a wedge under the right hip to help stopping their treatment and safely passes into breast . prevent aortocaval compression. Prepare becoming pregnant without increased risk There are also no documented studies the skin with alcohol or chlorhexidine as to the child (see Appendix in Part 1 of this of the effects of injectable filler in preg- povidone iodine is associated with fetal series).1 nancy. Filler injections can have adverse hypothyroidism in rare cases.12 Scarring Mild-to-moderate eczema in pregnancy effects that require the use of a dissolving may be worse in pregnancy, with a higher is routinely managed with emollients and substance such as hylauronidase, which is risk of scarring and recurrence of moderate-to-strong topical corticosteroids contra ­indicated in pregnancy. in pregnancy (Figures 2a and b).13 or topical calcineurin inhibitors. Among breastfeeding women, 2% develop eczema Management of skin cancer in Melanoma of the areola or nipple, and half of these pregnancy and breastfeeding Naevi do not undergo significant changes have a history of eczema. Nipple or areolar With the trend for women to delay child- specific to pregnancy but may stretch in eczema can be treated with moderate-to-­ bearing, GPs increasingly need the skills locations such as the abdomen and low potency topical corticosteroids and to manage melanoma and NMSC in preg- as girth increases.14 If the appearance of a ­moisturisers, applied after each feed. The nancy. ­One-third of women diagnosed naevus changes during pregnancy then the medications should be washed off with ­melanoma are of childbearing age.9 naevus should be removed and sent for ­thoroughly before the next feed. ­Melanoma accounts for up to 25% of all histopathological examination just as in a malignancies diagnosed during preg- nonpregnant woman.15 Cosmetic treatments nancy.9 The incidence of NMSC in women In the past, it was believed that women Despite the widespread use of botulinum in their 30s and 40s in Australia is diagnosed with melanoma in pregnancy toxin A for cosmetic purposes and a increasing.10,11 have poorer outcomes. This was based on

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should be treated in consultation with surgery is available then I tend to refer SKIN MEDICATIONS CONTRAINDICATED IN PREGNANCY (PREGNANCY ­specialised centres when possible. patients with nonurgent lesions for surgery CATEGORY)3 Malignant melanoma diagnosed dur- approximately six weeks postdelivery after ing pregnancy rarely metastasises to the careful monitoring of the lesion during Topical medications ­placenta or fetus. However, when this pregnancy. Adapalene (D) metastasis occurs it is typically in women Infiltrating and higher risk lesions need (uncategorised) with widespread metastatic disease.15 If to be excised during pregnancy as per usual Isotretinoin (X) Lindane (teratogen) malignant melanoma is detected in the management in nonpregnant patients. Minoxidil (C) placenta then there is an approximately (D) 25% chance of fetal metastases, and close Skin medications contraindicated Tazarotene (X) follow up of the infant is essential.15,17 in pregnancy and breastfeeding Tretinoin (D) Women who have been diagnosed with The safety during pregnancy of common Systemic medications a melanoma with poor prognostic factors medications for skin conditions was Acitretin (X) should be informed that the risk of recur- ­covered in detail in Part 1 of this series.1 Azathioprine (D)* rence is greatest within two to five years of A common concern additional to which Finasteride (X) Fluconazole (D) diagnosis, and subsequent pregnancy needs ­medications are safe in pregnancy is when 15 Hydroxychloroquine (D) to be considered in this light. The use of to advise cessation before conception. Intravenous immunoglobulin (C)† the oral contraceptive pill and ­ Patients should avoid any topical or oral Isotretinoin (X) replacement therapy in a patient previously medications (herbal or medical) or cosme- Methotrexate (D) diagnosed with melanoma does not appear ceuticals with unproven evidence of safety Mycophenolate mofetil (D) 15 (B3)‡ to negatively influence prognosis. in pregnancy and lactation in the period Tetracyclines (D) before conception. Methotrexate should * Despite being classed as category D, azathioprine Nonmelanoma skin cancer be ceased three months before and acitretin is most likely safe in pregnancy and has been widely used by pregnant women. To my knowledge, there are no statistics two years before conception. Medications † Clinical experience with immunoglobulin regarding the frequency of diagnosis or for skin conditions that are contraindicated preparations given during pregnancy suggests that there are no adverse effects on the fetus. the growth rate of NMSC in pregnancy. in pregnancy are listed in the Box. ‡ Use of spironolactone in pregnancy can feminise Nor are there specific treatment guide- the male fetus. Its use in pregnancy should be lines for the management of NMSC in Management of postpartum considered only when there are no alternatives and the benefit outweighs the risk (unllkely for pregnancy. skin problems dermatological indications). Nonsurgical treatments such as imiqui- Nipple and breast problems mod and photodynamic therapy are not Many breastfeeding women experience the assumption that pregnancy is a state of recommended for use in pregnancy. problems of the nipple, areola or breast. relative immunosuppression, which accel- ­Imiquimod is not recommended during A simple algorithm for the diagnosis and erates the transformation of melanocytic breastfeeding, although it is classed as management of nipple pain, cracking and naevi into melanoma and the process of ­category B1 in pregnancy. Photodynamic redness is shown in the flow chart. Early metastasis. However, studies have found therapy (category B2) is an option for breast- pain is most likely due to trauma second- no compelling evidence that pregnancy feeding with responsive tumours ary to poor infant latching or a bacterial adversely affects the prognosis in patients provided that is expressed and infection. Review with an experienced with clinically localised melanoma.16 discarded for 48 hours after the application is valuable. When Treatment of melanoma should follow of methyl amino­levulinate.18 this review is not available, evaluate the conventional guidelines relating to tumour The safety of monitoring nonurgent positioning of the baby during feeding thickness, ulceration, mitotic rate and superficial basal cell carcinomas and early and check the baby’s mouth for any palate ­overall stage of disease.15,11 Wide local exci- squamous cell carcinomas in situ (Bowen’s or oral anomalies. Recommend to the sion and, if required, sentinel lymph node disease) in pregnancy is not fully estab- mother that she position the infant’s body mapping can be performed safely in preg- lished. However, if the patient undergoes directly facing her, with ears, shoulders nancy.15 If evaluating for distant metastases regular monitoring then it may be reason- and hips in alignment. then a chest x-ray with appropriate shielding able to postpone treatment of biopsy-­proven A good history is important as the and ultrasound examination are safe. After nonurgent superficial NMSCs until after patient may have an underlying history of the first trimester, MRI is preferred over the birth. Mohs micrographic surgery offers atopic eczema or psoriasis. Make sure that CT scanning.15 Pregnant women with the highest chance of cure for NMSC and agents such as soaps and detergents are not thicker and nodal metastases the greatest tissue conservation. If Mohs being applied to the breast as they may

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A SUGGESTED ALGORITHM FOR MANAGEMENT OF BREASTFEEDING WOMEN WITH NIPPLE PAIN

Breastfeeding woman presents with nipple pain, cracking or redness

• Take detailed history • Examine breast and infant • Assess infant on

Red Milk , Poor infant Adequate infant latch on discolouration localised breast latch on of nipple tenderness

Patient is well Patient is unwell Nipple Plugged Suckling vasospasm lactiferous trauma ducts Negative swab Positive swab

• Refer to • Refer to • Refer to lactation lactation lactation consultant consultant consultant • Avoid triggers • Treat with Skin disorder • Warm antibiotics • If not if flu-like improving, try symptoms magnesium • Use Eczema Psoriasis Bacterial Fungal 300 mg daily (with well- infection infection or for pain demarcated (can progress (can progress plaque) to mastitis) to mastitis)

Endogenous Irritant contact Allergic contact Treat with Treat mother Treat with dermatitis dermatitis • topical and infant with • oral • Ask about • Ask about • Ask about • topical cefalexin, history of substances allergen exposure • oral miconazole • Test for raised applied to (e.g. chamomile, antibiotics (mother) or IgE level nipple aloe vera) if not • nystatin dicloxacillin improving drops or if bacterial miconazole • oral oral gel fluconazole (infant) if yeast Treat with topical corticosteroids, swab for secondary infection suspected cause an irritant reaction. Some t­opical infant for oral thrush and nappy . Breast the nipple, which may be associated with substances, such as aloe vera, may cause tenderness in association with fevers, changes in nipple colour. true allergic . Enquire malaise, headache and chills suggests If the history and examination suggest about any risk factors for Candida infec- ­mastitis, which is usually caused by a an infection then I generally recommend tion, such as recent use of antibiotics or a staphylo c­ occal infection. Localised redness ­taking swabs and milk samples for micros- history of gestational or ­vaginal of the breast in association with milk blisters copy and culture. My preferred samples thrush. Nipple usually presents may be due to a .19 Finally, and sampling technique for breastfeeding with later onset of new nipple pain and if the mother experiences cold sensitivity women with a suspected breast or nipple generally coincides with of the hands and feet then ­consider the rare infection are outlined in the Table. in the breastfeeding infant.19 Examine the possibility of Raynaud’s phenomenon of Treatment of women with a breast or

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Infection of the nipple or breast TABLE. PREFERRED SAMPLING FOR DIAGNOSIS OF INFECTIONS OF THE BREAST AND NIPPLE IN BREASTFEEDING WOMEN If a superficial bacterial infection of the nipple or breast is ­confirmed then the treat- Sample source Sampling technique ment of choice is topical mupirocin applied twice daily.19 Staphylococcus aureus For bacterial culture For fungal culture* is the most likely cause. Infant’s mouth Bacterial culture not Swab tongue, buccal mucosa and If either the mother or baby has signs required palate (avoid saliva as it has antifungal of Candida infection then both should properties) be treated simultaneously. Topical Mother’s skin Sample for bacterial culture Clean skin with an alcohol swab miconazole cream applied to the nipple (nipple and before fungal culture before sampling for fungal culture to after each feed is recommended. The mammary folds) avoid bacterial contamination infant can be treated with cautious use Mother’s milk Hand express milk; discard Fungal cultures are available for milk, of nystatin drops or a small amount of first 1 mL to avoid bacterial but check with local pathology miconazole oral gel applied to the front contamination from skin services of the mouth. Miconazole gel is thought * For fungal culture, moisten sample with saline before processing and process within 24 hours. to be more effective than nystatin, but too much gel may be hazardous, causing nipple infection or nipple eczema or pso- and then switch to the painful side. If pain throat or airway blockage.20 Candida riasis is outlined below. In addition, breast- precludes feeding then advise her to use a nappy rash should also be treated with feeding should be encouraged as much as , on a low setting if necessary. topical miconazole. possible. Advise the mother to start with If pain is significant then oral ibuprofen When infection is suspected or con- the nonpainful side, feed for 10 minutes is beneficial.19 firmed, it is sensible to advise sterilising

34 MedicineToday ❙ SEPTEMBER 2016, VOLUME 17, NUMBER 9 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. Eczema and psoriasis of the nipple to create a small bolus of corticosteroid If the nipple appears eczematous or there within the scar, avoiding overinjection into are features suggesting psoriasis (past surrounding normal tissue. The treatment history of psoriasis in the mother or a well is repeated every four to six weeks until the demarcated red rash) then a potent topical scar has flattened. If improvement is min- corticosteroid (ointment preferred over imal then the cortico­steroid dose may be cream) applied twice daily after a feed for increased, but care must be taken to avoid two weeks is recommended. The nipple complications such as atrophy. should be cleaned before the next feed. Conclusion Sagging skin Figure 3. Sagging abdominal skin Pregnancy has an unpredictable effect on postpartum. Abdominoplasty may be an Women often ask for advice about sagging pre-existing skin conditions such as acne, option if the patient has completed her abdominal or breast tissue following psoriasis and atopic eczema. Although . It is recommended to wait at least ­pregnancy and delivery (Figure 3). In my many drugs are contraindicated during nine months after the last birth before surgery. experience, topical or treatment does pregnancy, options exist for treating these not lead to noticeable improvement. If the conditions. Management of new melanoma patient has completed her family and is is not necessarily altered by pregnancy, but any equipment that comes in contact with very bothered by the appearance of the postponing treatment of superficial non­ breast milk (e.g. breast pumps, pacifers and sagging skin then I recommend referral urgent non-melanoma skin cancer until accessories). I recommend washing to a plastic surgeon for consideration of after the birth may be considered in some daily in hot with one cup of distilled abdominoplasty nine months after deliv- cases. Management of postpartum breast vinegar. Sensible additional advice includes ery. If women are concerned by breast and skin problems can be helped by a keeping the nipples dry, frequently chang- sagging then breast lift or augmentation ­simplified diagnostic approach and a con- ing breast pads and avoiding the use of may help. fident understanding of the safety of skin cloth breast pads. medications during breastfeeding. MT If topical treatments are ineffective or Caesarean scars if signs and symptoms of mastitis develop For women who have completed their References (e.g. ongoing breast tenderness, fever, f ­amily and have hypertrophic or keloid A list of references is included in the website version chills and malaise) then oral treatment scarring of the caesarean incision, intra­ of this article (www.medicinetoday.com.au). should be commenced. Mastitis (inflam- lesional corticosteroid treatment may be mation of the breast caused by obstruction warranted, especially if the scar is painful COMPETING INTERESTS: None. to milk flow) may progress to further or itchy. Photographing the scar at baseline breast infection and ultimately helps assess improvement. Realistic expec- ONLINE CPD JOURNAL PROGRAM formation if not managed effectively. tations should be encouraged by advising ­Bacteria or yeast may enter the milk ducts that the skin will not return completely What acne treatments are safe for via injury to the ­nipple, which can lead to to normal, but that the scar will flatten pregnant women? infective mastitis or a breast abscess. and become less painful and itchy. S. aureus is the most common cause of My procedure for intralesional cortico­ infective mastitis. steroid treatment is to inject the scar Women with mastitis caused by a with triamcinolone acetonide 20 mg/mL ­bacterial infection should be treated with (prepared by diluting 1 mL of triamci- cefalexin 1000 to 1500 mg/day, amoxicillin nolone acetonide 40 mg/mL with 1 mL of 1000 to 1500 mg/day or dicloxacillin lignocaine solution in a 3 mL Luer lock 750 mg/day for two to six weeks.19 When ). An alternative I sometimes use is a yeast infection is clinically suspected, oral to inject the scar with lignocaine first and fluconazole is an effective treatment.18 If then wait a few minutes before injecting Review your knowledge of this topic the patient does not improve within the diluted corticosteroid, to reduce the and earn CPD points by taking part approximately 48 hours after starting oral pain of injection. I inject along the scar in in MedicineToday’s Online CPD Journal antibiotics or antifungals then consider the approximately 1 cm2 units. The volume Program. Log in to possibility of an abscess or the need for injected depends on the size and thickness www.medicinetoday.com.au/cpd intravenous antibiotic therapy. of the scar, but generally should be enough

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NINA WINES BSc, MB BS, DRANZCOG, FACD

References

1. Wines N. Managing the skin in pregnancy. Part 1. Pregnancy-related skin 2005; 294: 681-690. concerns. Med Today 2016; 17(7): 25-34. 12. Richards KA, Stasko T. Dermatologic surgery and the pregnant patient. 2. Kong YL, Tey HL. Treatment of acne vulgaris during pregnancy and lactation. Dermatol Surg 2002; 28: 248-256. Drugs 2013; 73: 779-787. 13. Hyung-Do K, Hwang S, Lim K, Jung Y, Ahn S, Song J. Recurrent auricular 3. Murase J, Heller M, Butler D. Safety of dermatological medications in keloids during pregnancy. Arch Plast Surg 2013; 40: 70-72. pregnancy and lactation. Part 1 Pregnancy. J Am Acad Dermatol 2014; 14. Akturk AS, Bilen N, Bayramgurler D, et al. Dermoscopy is a suitable method 401.e1-e13. for observation of the pregnancy-related changes in melanocytic nevi. J Eur 4. Babalola O, Strober BE. Management of psoriasis in pregnancy. Dermatol Acad Dermatol Venereol 2007; 21: 1086-1090. Ther 2013; 26: 285-292. 15. Jhaveri MB, Driscoll MS, Grant-Kels JM. Melanoma in pregnancy. Clin 5. Park KK, Murase JE. Narrowband UV-B phototherapy during pregnancy and Obstet Gynecol 2011; 54: 537-545. folic acid depletion. Arch Dermatol 2012; 148: 132-133. 16. Brady MS, Noce NS. Pregnancy is not detrimental to the melanoma 6. Berthelot JM, De Bandt M, Goupille P, et al. CRI (Club Rhumatismes et patient with clinically localized disease. J Clin Aesthet Dermatol 2010; Inflammation). Exposition to anti-TNF drugs during pregnancy: outcome of 3: 22-28. 15 cases and review of literature. Joint Bone Spine 2009; 76: 28-34. 17. Driscoll MS, Grant-Kels JM. , nevi and melanoma: an approach 7. Weatherhead S, Robson SC, Reynolds NJ. Eczema in pregnancy. BMJ to the patient. J Am Acad Dermatol 2007; 57: 919-931. 2007; 335: 152-154. 18. Galderma Australia Pty Ltd. Product information Metvix®. Available online 8. Aranda MA. Botulinum toxin A during pregnancy, still a debate. Eur J at: https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/ Neurology 2012; 19: e81-e82. pdf?OpenAgent&id=CP-2011-PI-01041-3&d=2016062616114622483 9. Lens M, Bataille V. Melanoma in relation to reproductive and hormonal (accessed August 2016). factors in women: current review on controversial issues. Cancer Causes 19. Heller MM, Fullerton-Stone H, Murase JE. Caring for new mothers: diagnosis, Control 2008; 19: 437-442. management and treatment of nipple dermatitis in breastfeeding mothers. Int J 10. Fransen M, Karahalios A, Sharma N, English D, Giles G, Sinclair R. ­ Dermatol 2012; 51: 1149-1161. Non-melanoma skin cancer in Australia. Med J Aust 2012; 197: 565-568. 20. Hoppe JE, Hahn H. Randomized comparison of two nystatin oral gels with 11. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell miconazole oral gel for treatment of oral thrush in . Antimycotics Study and squamous cell carcinomas in a population younger than 40 years. JAMA Group. Infection 1996; 24: 136-139.

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