What is known about this subject in regard to women and their families?
It is known that acne is a common condition affecting pregnant women and that common treatments for acne are unsafe in pregnancy.
It is known that alternative treatments exist that are safe in pregnancy but actual treatment patterns are unclear.
What is new from this article as messages for women and their families?
This article demonstrates that inconsistencies exist for treatment of acne in pregnant women and treatment is not always in accordance with evidence-based guidelines.
It is important for women and physicians caring for pregnant women to familiarize themselves with ABFM guidelines for treatment of acne in pregnancy.
Dear Editors,
Acne vulgaris is an inflammatory disease of the skin common in pregnancy.1 Many first-line acne treatments are teratogenic, complicating management of this condition (Table 1).2 Although recommendations from the American Board of Family Medicine (ABFM) exist for treatment of acne in pregnancy,3 no studies have analyzed real-life data of acne management in pregnant patients.
Table 1.
Pregnancy class ratings of common acne medications
| Pregnancy class | Acne medications |
|---|---|
| A | None |
| B | Macrolides, clindamycin, azelaic acid, penicillin |
| C | Benzoyl peroxide, tretinoin, adapalene, dapsone, spironolactone, TMP-SMX |
| D | Tetracycline antibiotics |
| X | Tazarotene, isotretinoin |
A retrospective study utilizing patient data from the Northwestern Medicine Enterprise Data Warehouse was approved by the Northwestern University Institutional Review Board (STU00037913). Data from over 40 clinic locations and 100 providers across the Chicago metropolitan area resulted in 4,050 analyzed patient encounters with a diagnosis of acne vulgaris. One hundred fifteen of these visits occurred in pregnancy-related encounters.
Within our 115 patients, 57.4% (66) of patients were trying to get pregnant within the next year, 32.2% (37) were pregnant, and 10.4% (12) were breastfeeding (Table 2). Patients in this cohort were exclusively prescribed pregnancy category B and C medications.2 Azelaic acid 15% gel and clindamycin 1% gel, solution, or lotion were the most commonly prescribed treatments with 83.3% (55/66) and 69.7% (46/66) of patients trying to get pregnant and 75.7% (28/37) and 56.8% (21/37) of pregnant patients prescribed these medications, respectively. Only 13.5% (5/37) of currently pregnant patients were prescribed category C prescriptions, suggesting safe treatment of acne in pregnancy. In nonpregnancy-related encounters, prescription rates of azelaic acid (4.5%, 178/3,935) and clindamycin (54.0%, 2,124/3,935) were lower and recommendation rates of other pregnancy C medications including retinoids (59.8%, 2,355/3,935), spironolactone (10.2%, 401/3,935), and dapsone (9.1%, 358/3,935) were higher compared to pregnancy-related encounters. These findings suggest substantial adjustment of acne treatment regimens for safety in pregnancy and peri-pregnancy and recognition of the teratogenic effects of acne medications by providers.
Table 2.
Percentage of patients receiving each treatment by pregnancy category compared to nonpregnant patients
| Actively trying to get pregnant | Currently pregnant | Breastfeeding | Nonpregnant population | |
|---|---|---|---|---|
| Azelaic acid | 83.3 (55/66) | 75.7 (28/37) | 75.0 (9/12) | 4.5 (178/3,935) |
| Clindamycin | 69.7 (46/66) | 56.8 (21/37) | 66.7 (8/12) | 54.0 (2,124/3,935) |
| Benzoyl peroxide | 24.2 (16/66) | 13.5 (5/37) | 25.0 (3/12) | 46.4 (1,825/3,935) |
| Retinoid | 7.6 (5/66) | 0.0 (0/37) | 8.3 (1/12) | 59.8 (2,355/3,935) |
| Dapsone | 4.5 (3/66) | 0.0 (0/37) | 0.0 (0/12) | 9.1 (358/3,935) |
| Macrolides | 4.5 (3/66) | 16.2 (6/37) | 8.3 (1/12) | 2.3 (90/3,935) |
| Penicillin | 3.0 (2/66) | 0.0 (0/37) | 0.0 (0/12) | 0.7 (28/3,935) |
| Spironolactone | 0.0 (0/66) | 0.0 (0/37) | 8.3 (1/12) | 10.2 (401/3,935) |
| Pregnancy C | 33.3 (22/66) | 13.5 (5/37) | 33.3 (4/12) | – |
| Antibiotic monotherapy | 9.1 (6/66) | 16.2 (6/37) | 8.3 (1/12) | 6.9 (270/3,935) |
ABFM guidelines recommend avoidance of antibiotic monotherapy and encourage use of benzoyl peroxide as first-line treatment of acne in pregnancy to avoid antibiotic resistance.3,4 Of 37 pregnant patients, 6 (16.2%) were prescribed antibiotic monotherapy which was higher than the rate of 6.9% (270/3,935) in the nonpregnant population. Benzoyl peroxide 2.5–10% in the form of a face wash, cream, or gel was recommended at lower rates in the pregnant group (13.5%, 5/37) compared to those not pregnant (46.4%, 1,825/3,935). The higher rates of antibiotic monotherapy and lower rates of benzoyl peroxide prescribed in pregnant patients may reflect the limitations for ideal acne treatment and highlight a potential area for improvement.
One limitation of this study is the relatively small sample size. Although prescription trends and generalizations can be inferred from the data, the sample size is not large enough to determine statistical significance. Furthermore, all the patient data comes from a single healthcare system.
Overall, our data show significant adjustment of acne treatment regimens in pregnancy to account for the teratogenicity of common acne medications. However, the AAD identifies the treatment of acne in pregnant women as a research gap and there remains room for improvement. It is imperative for providers to heed attention to pregnancy medication classes and familiarize themselves with recommended guidelines for optimal patient management.
Conflicts of interest
None.
Funding
None.
Study approval
Reviewed and approved by Northwestern IRB; approval STU00037913.
Author contributions
SPG participated in research design, performance of the research, data analysis, and writing of the paper. SA participated in data analysis and writing of the paper. RVK participated in research design, performance of the research, and writing of the paper.
Footnotes
Published online 9 March 2023
References
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