PEER REVIEWED FEATURE 2 CPD POINTS Managing the skin in pregnancy Part 2. Pre-existing, new and postpartum skin conditions NINA WINES BSc, MB BS, DRANZCOG, FACD Management of pre-existing skin conditions, such as acne, psoriasis 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 nipple and breast 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 medication safety during trimester or delayed until after the birth if possible. breastfeeding. • Management of certain types of new melanoma is not necessarily altered by pregnancy. regnancy has unpredictable effects on pre-existing skin • In pregnant women with superficial nonurgent diseases 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 fetus as considered in some cases. • Management of postpartum nipple and breast problems Pwell as the mother. 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 medications and lactation, 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 non melanoma skin cancer (NMSC) in pregnancy is increasing. Postpartum, many women present to their GPs with problems of the nipple, areola 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. Dermatology; and a Visiting Medical Officer at The Skin Hospital, Sydney, NSW. MedicineToday ❙ SEPTEMBER 2016, VOLUME 17, NUMBER 9 27 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. MANAGING THE SKIN IN PREGNANCY continued 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 methotrexate 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 melasma 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 creams. b (right). The same patient four weeks after the birth, showing clearing of the acne. be ceased at least six months before conception (adalimumab, 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 woman 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 erythromycin 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 vitamin D 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-eclampsia 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, tacrolimus 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 cefalexin 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 prednisone 0.5 mg/kg combined When all other options are ineffective control before conception. Topical retinoids with a systemic antibiotic, in collaboration or impractical, referral to a dermatologist (adapalene, tretinoin 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 azelaic acid 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 infant 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 dermatitis 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 postpartum period.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 disease 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 placenta, and the small • avoiding irritants and allergens postpone conception after botulinum amount of epinephrine required for skin • encouraging