Retail Clinician CE Lesson

This lesson is supported by an educational grant from Union Swiss. Helping patients manage common -related skin conditions

Introduction with normal hormonal changes during tial benefits, safety and proper use of While pregnancy usually is character- pregnancy. Women with such pre-exist- nonprescription and prescription skin ized by symptoms of , ing skin diseases as eczema, psoriasis or creams and lotions. Understanding the constipation and backaches, a woman’s acne may see a worsening of symptoms different types of skin conditions, mech- skin also goes through many noticeable throughout pregnancy. anism for development and potential changes during her pregnancy. Stretch Pregnancy dermatoses are defined risk factors is the first step in being able marks probably are the most common as a rare group of inflammatory and to communicate with both the pregnant skin change that pregnant women expe- pruritic skin diseases specifically re- and postpartum patient. rience. However, a variety of other skin lated to pregnancy or immediately fol- conditions can occur not only through- lowing delivery.1 Many of these skin Pregnancy and the skin out pregnancy but postpartum as well. diseases that require healthcare pro- Hormones play a significant role It is estimated that vider referral develop in the last few in causing the various dermatological typically occur in up to 90% of pregnant weeks of pregnancy and can range changes observed during pregnancy or women by the third trimester or after from mild to severe. Although an excit- postpartum. Progesterone and estrogen the 24th week of gestation.1-3 There are ing time in a woman’s life, the physi- are the primary hormones for maintain- three categories of pregnancy-associated cal changes that accompany pregnancy ing pregnancy and development of the skin conditions that have been identi- and the come with . Both hormones continue to rise fied, including benign skin changes re- many concerns and questions. throughout pregnancy and appear to be sulting from normal hormonal changes, Accessibility of skin care products re- the primary risk factor for many of the exacerbation or changes in pre-existing quires the clinician to be knowledgeable pregnancy-related skin abnormalities. skin diseases and pregnancy-specific on managing common pregnancy-relat- Skin changes, especially those that are dermatoses.1 Stretch marks, hyperpig- ed skin conditions. Clinicians should be visible, can cause additional emotional mentation and vascular changes are able to effectively counsel the pregnant stress to the patient. It is necessary to classified as skin conditions associated and postpartum patient on the poten- identify the different skin conditions so

By: Brooke D. Fidler, PharmD, assistant professor 1. Describe the most common types of skin condi- tion, of which 1.00 (one) hour is accredited for phar- of pharmacy practice, Arnold & Marie Schwartz tions — including etiology and signs and symp- macology, by Partners in Healthcare Education, College of Pharmacy and Health Sciences, Long toms — that are associated with pregnancy. LLC, an approved provider of nurse practitioner Island University 2. Identify those patients during pregnancy continuing education by the American Academy of and postpartum who are eligible for self- Nurse Practitioners, provider No. 031206. Initial release date: Aug. 2, 2010 management versus those who may require Planned expiration date: Aug. 2, 2011 prescription treatment or referral. To obtain credit: Answer the test questions at the 3. Compare and contrast the different nonpre- end of this lesson, and complete the evaluation This program is accredited for 1.50 (one and scription products used in the treatment and online at RetailClinician.com. After completion of one-half) hours of continuing education credit, prevention of skin conditions during and after the post-test with a score of 70% or above, and of which 1.00 (one) hour is considered pharma- pregnancy. completion of the program evaluation, a printable cology credit. 4. Discuss the safety of topical and oral prod- certificate will be available. ucts used in this patient population. Program Goal: To improve the clinician’s ability to 5. Provide patient consultation on appropriate Questions regarding statements of credit provide consultation on management and preven- skin care techniques and other nonpharma- should be directed to W. Lane Edwards Jr. at tion of pregnancy-associated skin conditions. cological methods to care for skin during and [email protected]. This lesson is avail- after pregnancy. able free of charge to retail clinicians. Learning Objectives: Upon completion of this program, the clinician This independent learning activity is accredited for Copyright ©2010 by Lebhar-Friedman Inc. should be able to: 1.50 (one and one-half) hours of continuing educa- All rights reserved.

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that appropriate and safe treatment can skin, leading to stretch marks. of estrogen and progesterone, which be initiated along with the necessary A recent study by Osman et al. con- stimulate melanocytes to increase pro- nonpharmacological measures. cluded that risk factors for the devel- duction of melanin, the substance that opment of striae include younger ma- provides color to the skin and hair.6 Normal skin changes ternal age during pregnancy, family Hyperpigmentation of the face also is Stretch marks, hyperpigmentation history of developing striae, nonwhite referred to as gravidarum, and hair, nail and vascular changes all race, excess weight gain during preg- chloasma or the “mask of pregnancy.” It occur during pregnancy as a result of nancy, higher maternal body weight is characterized by brown, flat, blotchy normal hormonal changes. Some wom- and carrying a larger baby.3 The study patches that may appear on the fore- en may experience an increase in hair also concluded that the most common head, cheeks, nose, upper lip and chin, growth and thickness due to an altera- sites of striae are the abdomen and the or around the eyes. tion in the hair cycle. This excess in hair thighs and/or breasts, in 47% and 24% Melasma is more common and evi- typically is noticeable on the scalp but of women, respectively.3 dent in women with darker skin com- also may be present on the face, chest Since weight gain during pregnancy plexions.5 It is estimated that up to 70% and arms. This temporary state of hirsut- has been shown to correlate to the devel- of women will experience melasma ism may be bothersome to some women, opment of stretch marks, it is important during pregnancy, with higher rates ob- but they should be reassured that several for women to maintain a healthy diet served in Hispanic, Indian, Asian and months following delivery, hair cycles and manage their weight gain appropri- African-American populations.1,5,6 The should return to normal with normalized ately throughout pregnancy. The Ameri- condition can be worsened by excessive hormone levels. Similar to hair, nails also can College of Obstetricians and Gyne- sun exposure, resulting in an even dark- may undergo changes during pregnancy, cologists recommended a weight gain of er appearance to the skin. such as increased growth, brittleness and 25 lbs. to 37 lbs. for women of normal Pregnant women also may notice a indentations. These nail changes typi- weight before pregnancy.4 Underweight dark line that runs from the belly button cally resolve postpartum, but promot- women should gain between 28 lbs. and to the pubic region, which is referred to ing good nail hygiene is essential during 40 lbs., and overweight women should as linea nigra. This line is always there, pregnancy. Healthcare provider referral gain between 15 lbs. and 25 lbs. A wom- but prior to pregnancy, it is flesh colored should take place if hair and nail changes an who is concerned about her diet or and cannot be seen. In some cases of me- continue to occur or improvement is not excess weight gain should seek referral lasma, symptoms may persist for months seen months after delivery. to a nutritionist for appropriate counsel- or years following a pregnancy. Howev- ing and healthy meal-planning. er, hyperpigmentation generally is a self- Stretch mark scarring While not related to hormonal chang- limiting condition; areas of darker skin Stretch marks, also known as striae es during pregnancy, another type of gradually lighten after delivery when gravidarum, are characterized by thick scar that is part of a surgical delivery is hormone levels return to normal. or thin linear bands or streaks that may a Cesarean section scar. Nonprescrip- be present on the abdomen, buttocks, tion products used in the management Vascular changes breasts, thighs or arms. When they first of all types of scars, including stretch During pregnancy, the volume of develop they may appear pink, red or marks, contain ingredients that can help blood increases by 50%, which results purple in color. Stretch marks will nev- to promote scar fading, softening and in more blood circulation within the er completely go away, but they will smoothing. Even with no treatment, any body and changes to blood vessels.5,7,8 gradually fade over time. The streaks type of scar tissue will become softer Normal vascular changes that may oc- eventually will become silver, skin- and less red on its own. cur during pregnancy include spider toned or hypopigmented. veins, varicose veins and facial erythe- Stretch marks, also classified as atro- Hyperpigmentation ma. Increased blood circulation to the phic scars, result from thinning, dimin- Approximately 90% of pregnant face may cause a brightening to the face ished or reorganized skin elasticity and women will experience hyperpigmen- or the “pregnancy glow.” This, coupled strength.2,3 Although there is some con- tation of the skin.5 Common areas for with increased secretions of facial oil flicting evidence on the relationship, these darker spots include the breasts glands, also provides a shiny glow to stretch marks are thought to be caused and inner thighs. Scars, freckles or the face during pregnancy. Increased by rapid weight gain or stretching of moles already present on the body may blood circulation also may cause spider the skin. The higher levels of estrogen darken as well. The hyperpigmenta- veins, or spider nevi, to appear during during pregnancy, along with other hor- tion experienced during pregnancy is the first and second trimesters of preg- mones, also may cause a change to the thought to be caused by elevated levels nancy. They are tiny red blood vessels

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that form a web-like network on the these skin conditions. Increased pruri- ritus, hives, red plaques and fluid-filled face, neck, upper chest or arms. tus and worsening of dry and inflamed blisters found anywhere on the body. Unlike spider veins, varicose veins skin may be experienced during a flare. PUPPP and AEP are the most com- are larger, blue-colored veins that may Approximately one-third to one- mon of the dermatoses and are consid- appear most prominently on the legs, half of the cases of eczema, also known ered benign and self-limiting conditions. causing them to become swollen, sore as atopic , are seen during PUPPP may occur in 1-out-of-130-to-300 and prone to blood clots. Patients with pregnancy.11 Currently, there does not and usually develops dur- complaints of leg pain, swelling, warmth appear to be a link between having ec- ing the third trimester or immediately and redness should contact their health- zema or psoriasis and such adverse ef- postpartum.12 The rash is characterized care provider immediately as these could fects as birth defects or preterm delivery. by pruritic hives, papules or plaques be symptoms associated with deep vein However, it is necessary for clinicians to on the abdomen within stretch marks, thrombosis. During pregnancy, varicose know which patients plan on conceiving which may spread to the trunk and veins are caused by the excess weight and which ones are pregnant so appro- limbs. AEP may be observed in an es- and pressure of the uterus, which slows priate changes could be made to current timated 50% of pregnancies and can be down the extra blood flow circulating in drug regimens. Severe forms of skin seen at any time during pregnancy but the body. Risk factors for varicose veins disease that may be associated with sec- may linger postpartum.12 The rash pres- include multiple pregnancies, excess ondary skin infections should be treated ents with pruritic eczema-like lesions or weight gain during pregnancy, standing appropriately in order to decrease any small red nodules most commonly on or sitting for long periods of time and a potential risks to the mother or baby. the face, neck and extremities. family history of varicose veins.1,5,8 Both Pregnant women who present with types of blood vessel changes are nor- Pregnancy-specific dermatoses severe pruritus and an associated rash mal in pregnancy and typically resolve Unlike the conditions previously during any trimester should be referred following birth. Laser or surgical treat- reviewed, pregnancy dermatoses com- to their healthcare provider for a thor- ments are options for those patients who prise a rare group of skin diseases spe- ough examination so diagnosis and do not see improvement after a period of cifically related to pregnancy or the treatment can take place. In mild cases, time following a pregnancy. postpartum period. The hallmark symp- oral antihistamines or low- to moder- tom of these skin conditions is pruritus, ate-potency steroid creams can provide Pre-existing skin diseases which can be severe enough to disturb relief of the pruritus. In severe cases in Women with such pre-existing skin sleep and cause overall discomfort. In which the benefits outweigh the risks, conditions as eczema, psoriasis or acne 2006, Ambros-Rudolph et al. developed systemic steroids or high-potency topi- may notice a worsening or improve- and classified the four dermatoses of cal steroidal creams might be necessary. ment in their condition. Acne is consid- pregnancy. The dermatoses include ered both a pre-existing pemphigoid gestationis, or PG; pru- Skin care management and a normal skin change in pregnancy. ritic urticarial papules and plaques of The main goals of managing com- Women who have never had acne may pregnancy, or PUPPP; intrahepatic cho- mon pregnancy-related skin conditions experience pimples or irritated skin as lestasis of pregnancy, or ICP; and atopic are to ensure safety to the mother and a result of the increased oil gland secre- eruption of pregnancy, or AEP.12,13 baby, reduce the visibility of skin imper- tion during pregnancy. Women with an Of the four dermatoses, PG and ICP fections, manage associated symptoms existing acne problem may develop a present the most risk, including fetal and improve the impact that the poten- worsening of their condition. There is prematurity and distress, as well as sec- tial scarring has on the patient within a no way to determine who may experi- ondary skin infections for the mother reasonable amount of time. The choice ence a worsening or improvement in requiring immediate diagnosis and treat- of skin care product will depend on the an existing skin condition. However, ment. ICP is estimated to occur in 1-out- specific condition. Currently, there are some data have shown an opposite ef- of-150-to-1,300 pregnancies in the United nonprescription products available for fect in those women with eczema and States.12 It is the most common liver con- management of stretch marks, surgical psoriasis. Some women will see an im- dition that occurs during the third trimes- scars and hyperpigmentation. Nonmedi- provement in their psoriasis during ter of pregnancy and is characterized by cated moisturizers, sunscreens and oral pregnancy but a worsening postpar- jaundice and severe pruritus. PG is the antihistamines also play a role in self- tum, while others observe the opposite least common pregnancy dermatosis and managing the skin changes during preg- effect of their eczema.9,10 The altered is estimated to occur in 1-out-of-50,000 nancy. While there are numerous topi- levels of hormones during pregnancy pregnancies during the third trimester.12 cal products available for women to use appear to be the cause of exacerbating Symptoms include mild to severe pru- during and after pregnancy, it always is

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TABLE 1 Selected nonprescription stretch mark and scar products16-20

Topical Use in Use in medication Selected ingredients Indication Directions pregnancy lactation* Bio-Oil® PurCellin™ oil (vita- Indicated for scars, Use twice daily Yes Yes mins A and E, lavender, stretch marks, rosemary, calendula), uneven skin tone, sunflower and soybean oil aging skin and dehydrated skin

Kelo-cote® Silicone Helps treat, reduce, Apply once or twice No No scar gel prevent and soften daily for softening, scarring from sur- smoothing and flat- gery, wounds or tening hypertrophic injury, including or keloid scars C-section scars

Maternity Leaf extract, hyaluronic Helps prevent and Twice daily at be- Yes No Solutions® acid, vitamin E, colla- reduce the ap- ginning of pregnan- stretch marks gen, cocoa, aloe pearance of recent cy and for several cream stretch marks from months after birth earlier pregnancies or large weight loss

Mederma® Cephalen (onion extract), Indicated to reduce Use twice a day Yes Yes stretch marks hyaluronic acid, centella the appearance of therapy asiatica (leaf extract) stretch marks, re- advanced duce discoloration, cream formula improve texture and enhance softness

Palmer’s® cocoa Theobroma cacao (co- Helps improve the For use during and Yes Yes butter for stretch coa) extract, mineral oil, appearance of after pregnancy in marks collagen, elastin, vitamin stretch marks the morning and E, shea butter evening

ScarAway® for Silicone Flattens, softens Apply one silicone No Yes C-sections and fades scars sheet to C-section from C-sections and scar. Should be other surgeries worn for a minimum of 12 hours a day. Each sheet can be used for seven days. Do not use for more than 12 weeks.

Scarguard® Hydrocortisone, silicone, Indicated for scar Apply twice daily Yes No vitamin E management form- ing after injury or surgery

* All products applied to the breasts should be washed off breast and nipple area prior to nursing.

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important to consult a healthcare provid- usually is combined with vitamin E to Onion extract er prior to use to ensure safety. enhance the softening and soothing ef- Allium cepa, most commonly known fects of these natural fats.18 Cocoa butter, as onion extract, has been used in the treat- Stretch mark and surgical scar management as with other skin-conditioning agents, ment of numerous medical conditions, Since stretch marks are considered is indicated to penetrate deep dry skin, including skin scarring.21 Some proper- a type of scar, many products are ap- help restore vital moisture, smooth ties displayed by onion extract include proved for the management of both skin marks and tone skin. Therefore, these anti-inflammatory action and inhibition conditions, such as C-section scars and ingredients have been widely recom- of excess collagen synthesis and platelet stretch marks. In general, nonprescrip- mended for stretch marks during and aggregation. These proposed mechanisms tion products approved for the man- after pregnancy. of onion extract may explain its role in re- agement of scars are indicated to help Despite its popularity, there is conflict- ducing and softening the visibility of scars. new and existing scars resulting from ing data on the effectiveness of these in- There currently are no studies available surgery, injury, burns, acne and stretch gredients. In 2008, Osman et al. evaluated that have looked at the role of onion extract marks appear softer and smoother. the effectiveness of cocoa butter lotion for when topically applied to such atrophic Common ingredients that may be found the prevention of stretch marks in 175 scars as stretch marks. However, a limited in these products include onion extract, women starting in their first trimester.19 number of studies have compared onion essential oils, vitamin E and sunscreens. Two groups were observed: one that used extract versus placebo or standard thera- Indications for products with a focus a placebo lotion and another that used pies, such as petrolatum, on surgical scars. on improving the appearance of stretch cocoa butter lotion. Both groups used the Petrolatum emollient often is used as marks include restoring vital moisture lotions daily until delivery, and develop- a comparison agent when studying the and tone to the skin and smoothing ment of stretch marks on the abdomen, benefits of scar products. According to marks to the skin. These products may breasts and thighs were evaluated. The the American Academy of , include similar ingredients, such as es- authors concluded that there was no sta- petrolatum has been considered a stan- sential oils and vitamin E, plus cocoa tistically significant difference between dard in skin therapy by providing skin butter, hyaluronic acid, leaf extract, col- the study and placebo groups after evalu- protection and maintaining skin mois- lagen and elastin. ating development and severity of stretch ture, which can be beneficial for a dry and Table 1 lists selected nonprescription marks (45.1% versus 48.8%).19 pruritic scar.22 According to a 2006 release products indicated for scar and stretch In 2010, Buchanan et al. performed statement by the American Academy mark management and products that are a similar study in which 300 women, of Dermatology, studies have not fully considered safe to use during pregnancy starting from 16 weeks of pregnancy to substantiated the effectiveness of onion and lactation.14-18 It is important to edu- delivery, were either given cocoa butter extract in the improvement of scars due cate women who are breast-feeding that cream or placebo cream. Stretch marks to conflicting data. In addition, the AAD although a product may be suitable to developed in 44% of those using cocoa stated that various studies have shown use on the breasts to treat stretch marks, butter and 55% of those using placebo that onion extract is no more effective the medication should be removed or (P=0.09).20 Conclusions were similar, than other nonprescription products, such washed off prior to nursing. While there finding no significant benefits for the as petrolatum. Although the effectiveness are a multitude of products available use of cocoa butter in the prevention of may be questionable, pharmacists should for scars and stretch marks, limited evi- stretch marks. educate patients that no study has shown dence exists that these remedies are ef- Despite the lack of clinical evidence an adverse impact when using topical on- fective in the treatment or prevention of as shown by these study results, the ion extract. Therefore, the potential ben- these skin alterations. skin-conditioning agents cocoa and efits outweigh any risks associated with shea butter still are recommended and use of topical onion extract. Cocoa butter considered safe to use throughout preg- Cocoa butter, also known as Theo- nancy and postpartum. These ingredi- Essential oils broma cacao, is a vegetable fat extracted ents work by increasing moisture to the Essential oils are aromatic oils ob- from the cacao bean. Cocoa butter is skin, which provides skin with a softer tained by a physical process from an used as a skin-conditioning and mois- appearance, improves skin elasticity, odorous plant material of a single bo- turizing agent that softens and protects enhances hydration and limits skin ir- tanical. Different parts of the plant can the skin. Another common skin-condi- ritation. All of these factors can benefit be used to obtain essential oils, including tioning agent is shea butter, which is a women who have dry, irritated, itchy the flowers, leaves, seeds, roots, stems, natural fat extracted from the seed of the skin associated with the various skin bark or wood. Essential oils are the basic African karite tree. Cocoa or shea butter conditions throughout pregnancy. materials of aromatherapy and can be

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utilized either by inhalation or topically. When topically applied, the essential oils Patient case 1 enter the circulatory system by either massaging into the skin or placing the es- Mrs. Waters is a 35-year-old female who is pregnant with her first child. She sential oils in baths, lotions or dressings. is in her first trimester at 12 weeks. She presents to your clinic with com- Most products that contain essential plaints of itchy and dry skin predominantly on her abdomen and breasts. oils use a combination of the oils to pro- She also claims to see the beginning of stretch marks in those areas. She is vide a synergistic effect. Essential oils concerned about seeing stretch marks so early in her pregnancy and would have potential uses in skin care, includ- like to know if there is a product that you would recommend for her stretch ing all types of scars, stretch marks, un- marks and associated symptoms. even skin tone and dehydrated and aging skin.23 Vitamins A and E, lavender, rose- Case discussion mary, calendula, sunflower and soybean Stretch marks are a normal skin change that can take place during pregnancy. oil are some of the oils used in skin care Although typically seen during the third trimester, they can appear at any time, products. They have multiple mecha- causing the skin in those areas to be dry and itchy. The primary goal for this nisms, such as improving skin elasticity, patient is to minimize her itchy skin, restore the skin’s moisture, improve skin texture and tone; skin-conditioning; and tone and elasticity, and provide a smoother appearance to any scarring. Such providing a soothing and calming effect ingredients as essential oils, cocoa butter, onion extract, hyaluronic acid and to the skin.14 Essential oils topically used vitamin E all can benefit this patient. Although there are few studies substan- are considered safe to use throughout tiating their true effectiveness, they are considered safe to use during and after pregnancy and lactation but should be pregnancy, and have shown no adverse effects. Moisturizing the skin through- washed off prior to nursing.14 out pregnancy is key, and it is best to apply a cream or lotion after bathing. Unfortunately, there is limited clinical Massaging or rubbing any visible stretch marks in a circular motion can help evidence on the use of essential oils in the to break up scar tissue and provide a smoother appearance to the skin. management of stretch marks and scars. The majority of studies evaluating the use of essential oils have been in basic wound tion with other skin care ingredients, they teins responsible for elasticity, tone and care. In 2007, Woollard et al. conducted a may provide benefits to those looking for texture, and also are found in skin care literature review of the current evidence a better appearance to their scarring. products. These ingredients may have on the use of lavender, chamomile, thyme a potential role as a result of the dimin- and tea tree in wound healing.24 In a five- Other ingredients ished skin elasticity and tone that has subject study using dressings containing Stretch mark and scar management been affected by stretch marks. a combination of lavender and chamo- products typically are found with mul- Except for vitamin E, there are few mile on chronic wounds, those treated tiple ingredients to provide different studies individually looking at these in- with the essential oils healed more quick- mechanisms of action that may benefit gredients. Young et al. analyzed some of ly than the control group. This literature various types of scars. Vitamin E, aloe these trials to determine if there is an ef- review summarized the potential effects vera and hyaluronic acid work as hy- fective combination product to use in the of various essential oils, including anti- drating agents to soften and moistur- prevention or treatment of stretch marks bacterial and antifungal activity, stimu- ize scarred skin tissue. Leaf extract, also during pregnancy. One study, which com- lating new skin cell growth and anti- known as centella asiatica or gotu kola pared placebo cream to a combination inflammatory effects. extract, is another ingredient found in cream of leaf extract, vitamin E, collagen In a small four-month study conduct- scar and stretch mark lotions and creams. and elastin, found that less women devel- ed by an international clinical test labo- Potential dermatological benefits of leaf oped stretch marks using the study medi- ratory in 2005, 20 women between the extract include strengthening and firm- cation.25 Although there was no placebo ages of 18 and 55 years with abdominal ing of the skin, increasing skin collagen for comparison, another study showed stretch marks were asked to apply vita- and increasing blood supply to inflamed benefit in the prevention of stretch marks mins A and E, lavender, rosemary, calen- skin tissues.21 For these mechanisms, leaf when using a combination of vitamin E, dula, sunflower and soybean oil twice a extract commonly is used throughout hyaluronic acid and elastin.26 day.14 Half of the participants noticed an pregnancy and post-delivery to minimize Silicone and hydrocortisone are other improvement in their stretch marks after scar appearance due to stretch marks or ingredients that may benefit thickened four weeks. Based on the potential mech- surgical C-sections. or pruritic scars, respectively. Silicone anism of the oils and their use in combina- Collagen and elastin are the skin pro- can aid in flattening, smoothing and

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softening scars, which explains its ben- Hyperpigmentation management cludes prescription agents.6,17,27 Women efits on thicker scars. Hydroquinone is the primary ingre- should be aware that products contain- Sunscreens also are part of many dient found in nonprescription hypopig- ing hydroquinone, especially the non- skin care products and protect any type menting agents. These products are in- prescription strengths, do not work im- of scarring from getting darker in color, dicated to remove dark spots, freckles mediately. Results may not be observed especially if present on a sun-exposed and other skin discolorations that may for an average of four weeks, with a area of the body. be caused by age, the sun, minor scars, range between three weeks and three Clinicians should educate patients pregnancy or contraception use. Hydro- months.6 Any hydroquinone product that there are many factors that can af- quinone, a lightening agent, is thought should be discontinued if improvement fect the development of stretch marks, to interact with melanin production in is not seen within three months.6 and while there is inconclusive data on the lower layers of the epidermis, result- Sun exposure works against the mech- the benefits of these products, they can ing in a gradual fading of the darkened anism of hydroquinone, causing increased still provide adequate skin hydration, skin areas.6 Nonprescription hydroqui- production of melanin. Since this can ex- moisturizing and a softer appearance none contains 2% of the active ingredi- acerbate a patient’s condition and cause to the skin. Referral to a dermatologist ent, and prescription strengths are avail- further darkening of the skin, it is recom- should take place if the patient is look- able as 3% and 4% concentrations. mended that any hydroquinone product ing for a quicker and more aggressive Table 2 lists selected nonprescription be used in conjunction with a sunscreen. treatment to remove the scarring. hypopigmenting agents, and Table 3 in- The American Academy of Dermatology and the American Cancer Society recom- mend the use of a broad-spectrum sun- TABLE 2 screen with an SPF of 30 and containing 19 Selected nonprescription hyperpigmentation products both UVA and UVB protection. For patients who may not be adherent with this regimen, there are combination Topical medication Selected ingredients products available that contain both hy- ® Ambi Hydroquinone, padimate O (sunscreen), vitamin droquinone and such sunscreens as pa- E, alpha hydroxy acid ra-aminobenzoic acid, or PABA; octinox- Alpha Hydrox® Spot Light Hydroquinone, alpha hydroxy acid, vitamin E ate; and padimate O. Glycolic acid, an targeted skin lightener alpha hydroxy acid, is another ingredi- Esoterica® Hydroquinone, octyl dimethyl, para-aminoben- ent found in hypopigmenting products. zoic acid (PABA), benzophenone-3 It works to increase the skin’s texture, in- PorcelanaTM Hydroquinone, octinoxate creases growth of skin cells and quickly removes hyperpigmented skin cells.27 Palmer’s® Skin Success Hydroquinone, octyl salicylate, vitamin E, alpha eventone fade cream hydroxy acid It is recommended that hydroqui- none-containing products only be used on the face and very small affected ar- eas once to twice daily. It is not meant to be used on the body or darkened TABLE 3 areas covering a large portion of the Selected hydroquinone prescription products body. While all hydroquinone-contain- ing products have been assigned preg- nancy category C by the Food and Drug Brand/product Ingredients Administration and are indicated for ® Melquin-3 topical solution Hydroquinone 3% use during pregnancy, manufacturers Lustra® topical cream Hydroquinone 4% still recommend that pregnant or lactat- Melquin® HP cream ing patients contact their healthcare pro- ® Claripel topical cream viders prior to use.28 Lustra-Ultra® Hydroquinone 4%, retinol (sunscreen) 0.3% Since 2006, the FDA has voiced con- Lustra-AF® Hydroquinone 4%, glycolic acid (AHA), cerns over the safety of hydroquinone avobenzone (sunscreen) and its continued marketing of the product. Until a sufficient amount of data is available to show that there is a

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higher benefit–to-risk ratio when using Management of pre-existing skin conditions topical formulations. However, the Amer- the products, it is recommended by the Management of worsening pre-ex- ican Pregnancy Association recommends agency to advise against the use in preg- isting skin diseases, such as acne, ecze- consulting a healthcare provider prior to nant patients for self-management of ma and psoriasis, in pregnancy always using medicated acne products to weigh hyperpigmentation.28 For patients who should begin with proper skin hygiene. the risks against the benefits.29,30 are prescribed hydroquinone products, Consultation for those with acne should Such prescription medications as counseling should include information include eating healthy foods, cleansing topical retinoids, oral tetracycline and about such potential side effects as skin the face twice a day to minimize the ex- oral isotretinoin must be avoided during irritation, contact dermatitis, acne and cess oil, washing with an oil-free mild pregnancy.30,31 Women should notify their hypopigmenation in the area of treat- soap and following with an application healthcare providers if they currently are ment. Patients who show no improve- of an oil-free moisturizer. In order to taking these medications and trying to ment with the use of nonprescription- avoid facial scarring, it is important not become pregnant. Skin care techniques strength hydroquinone postpartum may to pick at the pimples or excessively rub for women who experience flares of ec- be candidates for prescription-strength the skin. Topical benzoyl peroxide and zema or psoriasis include avoiding hot hydroquinone, topical tretinoin, topical salicylic acid, both pregnancy category C, water when bathing; taking short, luke- corticosteroids or laser treatments.1 are available in nonprescription-strength warm baths or showers; applying a non- fragrant moisturizer several times a day, including after bathing; avoiding prod- Patient case 2 ucts that exfoliate the skin; and applying a cool compress to itchy areas.9 These skin Mrs. James is a 36-year-old African-American female who has been a patient care recommendations also can benefit at your clinic for several years. She is three months postpartum with her sec- women who experience pruritus associ- ond child and not currently breast-feeding. She presents to your clinic with ated with pregnancy dermatoses. complaints of “darkened areas on her face that will not fade.” She explains When nonpharmacological measures that during her second pregnancy, she noticed darkened blotchy spots on do not provide symptomatic improve- her face, specifically on her cheeks and nose. She did not experience this dur- ment, low to moderate topical corti- ing her first pregnancy and was hoping the spots would fade after she gave costeroid potency may be considered birth. She would like to know if there are any products, besides concealers, first-line treatment for mild to - moder that would remove or fade these spots. ate eczema in pregnancy.9 High-potency topical corticosteroids and systemic ste- Case discussion roids generally are avoided during preg- Mrs. James has experienced pregnancy-induced hyperpigmentation, which is nancy. When topical steroids fail to treat a common skin change during pregnancy due to hormonal changes. In many a flare-up of a pre-existing skin condition cases, these darkened or blotchy areas will fade. However, the condition may in pregnancy, ultraviolet light therapy is continue to persist after giving birth. Hydroquinone is the primary ingredient considered the safest second-line course found in nonprescription hypopigmenting agents. These products are indi- of treatment. Other treatments approved cated to remove dark spots, freckles and other skin discolorations that may be for eczema, such as the calcineurin in- caused by age, the sun, minor scars, pregnancy or contraception use. hibitors tacrolimus and pimecrolimus, Mrs. James could begin with a nonprescription hydroquinone product have not been fully evaluated in preg- available as a 2% formulation. She should be counseled that results may not nancy and therefore should be avoided be observed for approximately a month, and she should discontinue the prod- in this population.9 uct and return to the clinic in three months if improvement is not seen. The Treatment for uncontrolled psoria- product should be used only on the face to treat the affected areas, and the sis during pregnancy should focus on patient may observe some skin irritation from the medication. Since sun ex- the use of ultraviolet light therapy and posure can further darken the skin, it is important for Mrs. James to either ap- limited amounts of low-potency topical ply a separate broad-spectrum sunscreen to her face when outdoors or choose steroids. Since there is no clear evidence a product that has a combination of hydroquinone and various sunscreens. of the risk on a fetus, other topical treat- Recommending prescription-strength hydroquinone, which is available ments should be avoided during preg- as 3% and 4% formulations or referral to a dermatologist for more aggres- nancy and lactation unless the benefits sive treatments, would be the next step for this patient if the nonprescription outweigh the risks.31 The specific preg- products did not remove or lighten the affected areas. nancy category of a drug always should be evaluated when determining a drug

8 • Fall 2010 RetailClinician.com Retail Clinician Retail Clinician CE Lesson

TABLE 4 Practice points FDA pregnancy category X medications*31,32 1. The three categories of pregnancy-associated skin conditions include be- nign skin changes, changes in pre-existing skin disease and pregnancy- Drug Indication specific dermatoses. Acitretin Psoriasis 2. Other than stretch marks and surgical scarring, which will only fade, oth- Methotrexate Psoriasis er pregnancy-related skin conditions typically resolve postpartum. 3. Essential oils, onion extract, cocoa butter, vitamin E, hyaluronic acid, sun- Tazarotene Psoriasis screens and hydroquinone are just a few of the ingredients found in non- Isotretinoin Acne prescription skin care products. * FDA definition of category X drugs: Studies 4. Appropriate skin care techniques always should be followed throughout in animals or human beings have demonstrat- ed fetal abnormalities, or there is evidence of pregnancy to minimize potential skin changes. fetal risk based on human experience or both, 5. Women who are pregnant or nursing postpartum always should con- and the risk of the use of the drug in pregnant women clearly outweighs any possible sult with their healthcare provider to ensure the safety of using products benefit. The drug is contraindicated in women throughout pregnancy or during lactation. who are or may become pregnant.

regimen for a patient trying to conceive issue for a patient. Unfortunately, there is no way to know or who already is pregnant. Table 4 lists who will develop pregnancy-related the dermatological pregnancy category Conclusion skin diseases. Focusing on nonpharma- X medications that must be avoided Clinicians should reassure patients cological measures is the first step in during pregnancy or if planning to be- that — with the exception of stretch the prevention or management of these come pregnant.31 While medication use marks or C-section scars, which will various skin conditions. When lifestyle in pregnancy always should be dis- only fade — the majority of skin chang- changes fail to help a patient manage cussed with a healthcare provider, an es that occur during pregnancy will their symptoms, the clinician should oral antihistamine or nonprescription- resolve themselves postpartum. How- consider topical or oral nonprescription strength steroidal cream may be ben- ever, if symptoms persist or worsen, the products as a first-line treatment prior eficial if pruritus becomes a significant patient should seek medical attention. to using prescription medications.

1 Tunzi M and Gray GR. Common Skin Conditions During Pregnancy. American Family Physician. 2007; 75:211-8. 2 Chang AL et al. Risk factors associated with striae gravidarum. Journal of the American Academy of Dermatology. 2004; 51:881-5. 3 Osman H et al. Risk Factors for the development of striae gravidarum. American Journal of & Gynecology. 2007 January; 196(1):62.e1-62.e5. 4 American Pregnancy Association. About Pregnancy Weight Gain. Available at www.americanpregnancy.org. Accessed March 2010. 5 American College of Obstetricians and Gynecologists. Skin Conditions During Pregnancy educa- tion pamphlet. Available at www.acog.org. Accessed March 2010. 6 Pray WS. Skin Hyperpigmentation. In Nonprescription Product Therapeutics. Lippincott: Philadelphia, PA. Second edition. Chapter 37. 7 Merck Manual. Physical Changes: Normal Pregnancy. Available at www.merck.com. Accessed March 2010. 8 American Pregnancy Association. Skin Changes During Pregnancy. Available at www.americanpregnancy.org. Accessed March 2010. 9 American Academy of Dermatology. EczemaNet. Treating Eczema During Pregnancy. Available at www.skincarephysicians.com. Accessed March 2010. 10 American Academy of Dermatology. PsoriasisNet. Psoriasis Triggers. Available at www.skincarephysicians.com. Accessed March 2010. 11 Dermatitis Facts. Atopic Dermatitis (Eczema) in Pregnancy. Available at www.dermatitisfacts.com. Accessed March 2010. 12 Roth MM. Specific Pregnancy Dermatoses. Dermatology Nursing. 2009;21(2):70-74,81. 13 Ambros-Rudolph CM et al. The specific dermatoses of pregnancy revisited and reclassified: Results of a retrospective two-center study of 505 pregnant patients. JAAD. March 2006; Volume 54(3):395-404. 14 Bio-Oil®. Available at http://www.bio-oil.info/en/uses.html. Accessed March 2010. 15 Me- derma®. Merz Pharmaceuticals, LLC. Greensboro, NC. Available at www.mederma.com. Accessed March 2010. 16 Scar Zone®. CCA Industries. East Rutherford, NJ. 2008. Available at www.scarzone.com. Accessed March 2010. 17 Drugstore.com Online Pharmacy. 1999-2009. Drugstore.com. Available at www.drugstore. com. Accessed March 2010. 18 Plamer’s. E.T. Browne Drug Co. Englewood Cliffs, NJ. Available at www.etbrowne.com. Accessed March 2010. 19 Osman H et al. Cocoa butter lotion for prevention of striae gravidarum: a double-blind, randomized and placebo-controlled trial. BJOG. 2008 Aug; 115(9):1138-42. 20 Buchanan K et al. Prevention of striae gravidarum with cocoa butter cream. International Journal of Gynecology & Obstetrics. 2010 Jan;108(1):65-8. 21 World Health Organization. Monographs on selected medicinal plants. Volume 1: 1999: 1-295. Available at http://whqlibdoc.who.int/publications/1999/9241545178. pdf. Accessed March 2010. 22 American Academy of Dermatology. Release Statement: Fading From Sight: New Advances To Minimize Surgical Scars. March 3, 2006. Available at www.aad.org. Accessed March 2010. 23 National Cancer Institute. Aromatherapy and Essential Oils Questions and Answers. Last modified May 2008. Available at www.cancer.gov. Accessed March 2010. 24 Woollard AC, Tatham KC, Barker. The influence of essential oils on the process of wound healing: a review of the current evidence. Journal of Wound Care. 2007;16(6):255-257. 25 Young G and Jewell D. Creams for preventing stretch marks in preg- nancy. Cochrane Database of Systemic Reviews. 1996, Issue 1. 26 Mallol J et al. Prophylaxis of striae gravidarum with a topical formulation. A double-blind trial. International Journal of Cosmetic Science. 1991 Feb; 13(1):51-7. 27 Gupta AK and Ryder JE. Lustra®, Lustra-AF® and Alustra™. Skin Therapy Letter. Volume 8. Number 5. June 2003. Available at www.skintherapyletter.com. Accessed March 2010. 28 Food and Drug Administration. Skin Bleaching Drug Products For Over-the-Counter Human Use; Proposed Rule. Federal Register. Aug. 29, 2006. Volume 71, Number 167. Pages 51146-51155. 29 American Pregnancy Associa- tion. Acne Treatment During Pregnancy. Available at www.americanpregnancy.org. Accessed March 2010. 30 American Academy of Dermatology. AcneNet. Acne Medications Not for Use During Pregnancy. Available at www.skincarephysicians.com. Accessed March 2010. 31 National Psoriasis Foundation. About Psoriasis: Conception and Pregnancy. Available at www.psoriasis.org. Accessed March 2010.

Retail Clinician RetailClinician.com Fall 2010 • 9 Retail Clinician CE Lesson

Helping patients manage common pregnancy-related skin conditions

Learning Assessment

Successful completion of “Helping 4. Which is the hallmark symptom of 8. Potential mechanisms of leaf extract, patients manage common pregnancy- all pregnancy-specific dermatoses? or gotu kola, in stretch mark prod- related skin conditions” is accredited for a. Skin inflammation ucts include which of the following? 1.5 (one and one-half) hours of continu- b. Papules a. Anti-pruritic ing education credit, of which 1.00 (one) c. Hives b. Increase skin collagen hour is considered pharmacology credit. d. Pruritus c. Improve skin elasticity To obtain credit, answer the following d. Skin conditioning questions and complete the evaluation online at RetailClinician.com. 5. Which of the following pregnancy- specific dermatoses is considered 9. Which of the following is considered benign and self-limiting? first-line treatment if pharmacolog- 1. Which of the following can be clas- a. PUPPP ical measures are necessary to man- sified as a normal skin change in b. PG age flares of eczema in a pregnant pregnancy? c. AEP patient? a. Stretch marks d. A and C only a. UV light therapy b. Acne b. Oral systemic steroids c. Hyperpigmentation c. Calcineurin inhibitors d. A and C only 6. Nonprescription hydroquinone- d. Low-moderate potency topical e. All of the above containing products should not be steroids used for longer than ___ month(s). a. One 2. Studies have shown which of the b. Two 10. All of the following medications following factors to have a positive c. Three are classified as pregnancy category correlation with stretch marks? d. Four X in the management of psoriasis a. Older maternal age during EXCEPT: pregnancy a. Oral methotrexate b. Family history 7. Which of the following ingredients b. Topical tazarotene c. Caucasian race is indicated to flatten and smooth c. Topical low-potency steroids d. Carrying a small baby thicker scars, such as C-section scars? d. Oral acitretin a. Cocoa butter b. Silicone 3. Melasma is more noticeable in women c. Hyaluronic acid with lighter skin complexions. d. Leaf extract a. True b. False

10 • Fall 2010 RetailClinician.com Retail Clinician