Pregnancy and dermatologic therapy

Kelly H. Tyler, MD, FACOG, and Matthew J. Zirwas, MD, FAAD

Columbus, Ohio

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Dermatologists should be familiar with medication safety in pregnancy to be able to prescribe safely andconfidently to pregnant women or women who may become pregnant during the course of treatment fordermatologic conditions. Topical medications should be considered first-line therapy for pregnant women,but certain systemic medications are safe to use in pregnancy and may be prescribed if necessary.Dermatologic surgery may be performed during the second trimester of pregnancy with properpositioning, but elective procedures should be delayed until the postpartum period. ( J Am Acad Dermatol2013;68:663-71.)

Key words: dermatologic surgery; dermatologic therapy; medication safety; pregnancy; systemic medi-cations; topical medications.

Women present to their physicians with avariety of skin disorders in the pregnantand nonpregnant state, with certain der-

matoses encountered only during pregnancy.1 Thesewomen typically present first to their obstetriciansduring routine visits, but they sometimes requirereferral to a dermatologist for continued treatment ofpre-existing or new skin symptoms. Female derma-tologic patients may also become pregnant duringthe treatment of their skin disease. It is important,therefore, for dermatologists to be able to prescribesafely and confidently to pregnant women andwomen who may become pregnant.

DRUG CLASSIFICATION FOR PREGNANCYBirth defects related to the use of diethylstilbestrol

and thalidomide in the mid-20th century led to thedevelopment of the Food and Drug Administration(FDA) Pregnancy and Lactation Categories.2 One of 5categories is assigned to each drug before it isreleased.3 Because of the impossibility of conductingcontrolled studies with medication use in pregnantwomen, these categories reflect a risk-benefit ratiobased on animal studies or epidemiologic data.4 Theclassifications are included in Table I.3

Although the FDA pregnancy classifications arethe most widely used, other sources for determiningthe safety of a medication during pregnancy includeTeratogen Information Service, Reproductive

the Division of Dermatology, Ohio State University.

ing sources: None.

osure: Dr Zirwas has acted as a consultant for Smart Practice,

nset, Taro, and Valeant. Dr Tyler has no conflicts of interest to

clare.

int requests: Kelly H. Tyler, MD, FACOG, 911 Neil Ave,

olumbus, OH 43215. E-mail: hoskins.kelly@gmail.com.

Toxicology Service (www.reprotox.org), Drugs inPregnancy and Lactation by Briggs et al,5 USPharmacopeial Dispensing Information,6 and casereports.3 Because the FDA can be slow to update theratings based on the most recent data and research,sources such as the Reproductive Toxicology ServiceWorld Wide Web site may be more up to date.1

TIMELINE FOR RISKWhen prescribing a medication, it is important to

determine whether a patient is actively preventingpregnancy with contraception, trying to conceive ornot preventing pregnancy, or is currently pregnant ina specific trimester and/or period of development(preimplantation, embryonic, or fetal).1

For sexually active women not on contraception,there is an 85% chance of becoming pregnant within1 year.7 Avoiding potentially teratogenic agents dur-ing the embryonic period, which is the secondthrough the eighth week after conception whenorganogenesis occurs, is especially important.1

Because some women will not have a positivehome pregnancy test result until up to 5 weeks afterconception, these patients should be treated withmedications that are safe during pregnancy.1

Although the highest period of risk is during orga-nogenesis, certain structures, such as the brain, teeth,and bones, remain susceptible after 9 weeks. Thus,some medications that do not cause harm during

Published online November 21, 2012.

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� 2012 by the American Academy of Dermatology, Inc.

http://dx.doi.org/10.1016/j.jaad.2012.09.034

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organogenesis may cause complications later inpregnancy.1

TOPICAL MEDICATIONS DURINGPREGNANCY

For most dermatologic conditions in pregnancy,topical treatments remain the safest choice

CAPSULE SUMMARY

d There are 3 distinct periods ofdevelopment during pregnancy:preimplantation (0-2 weeks), embryonic/organogenesis (2-8 weeks), and fetal (9thweek to birth).

d The risk associated with any givenmedication varies substantially over thecourse of these periods, with somemedications presenting risk primarilyearly in pregnancy and others presentingrisk primarily late in pregnancy.

d With appropriate steps, dermatologicsurgery and procedures can generally besafely performed during pregnancywhen necessary.

and should be consideredfirst-line therapy. Table IIsummarizes the pregnancyclassifications and risks ofeach topical medication.

Acne and rosaceaFor acne and rosacea, a

plethora of topical medica-tions are available, most ofwhich are safe for use duringpregnancy. The topical reti-noids tretinoin and adapa-lene are category C. Somestudies suggest that topicaltretinoin is teratogenic inthe first trimester,8-10 but an-other study contradicts thatfinding.11 Absorption is min-imal, and risk is unlikely, butalternative treatments should

be considered in the first trimester if they are avail-able.12 Adapalene, also category C, has minimalabsorption, so use during pregnancy could be con-sidered once the benefits and risks have beendiscussed with the patient.12 Data suggest that thepotential risk of teratogenicity of both agents is onlyduring the first trimester, and no problems have beenreported in studies where use occurs in the secondand third trimester.12 A practical approach would beto consider treatment with these agents after the firsttrimester in consultation with the patient’s obstetri-cian. Topical tazarotene, on the other hand, iscategory X because of retinoid-like anomalies foundin animal studies, so it is contraindicated.12

Antibacterial topical agents used for acne androsacea include clindamycin, erythromycin, andmetronidazole, all of which are category B and safethroughout pregnancy.12 Topical dapsone, a cate-gory C medication, has been used safely as an oralmedication in pregnancy for both leprosy and der-matitis herpetiformis, and no fetal risks are reportedin the literature.12 There is a theoretical risk ofneonatal hyperbilirubinemia when used near thetime of delivery, so the prescribing physician shouldconsider stopping treatment before the last month ofpregnancy.12 Topical sodium sulfacetamide, on theother hand, is a category C medication that is not

associated with hyperbilirubinemia, so its use is notcontraindicated anytime during pregnancy.12 Thenonantibacterial antiacne product benzoyl peroxideis category C because human studies have not beenconducted, but it is considered safe to use duringpregnancy and is a treatment of choice for acne inpregnant patients.1,4,12 Salicylic acid, another non-

antibacterial antiacne pro-duct, is also category C.Although this is an nonste-roidal anti-inflammatorydrug, which is generally con-traindicated in pregnancybecause of the potential foroligohydramnios and earlyclosure of the ductus arterio-sus in the third trimester,1 thesystemic absorption is esti-mated to be between 9%and 25%.13-15 Because of itsminimal absorption, there isa very low teratogenic poten-tial,16 and pregnant womenshould simply be advised notto apply topical salicylic acidfor prolonged periods overlarge areas or under occlu-sive dressings, which would

enhance systemic absorption. Azelaic acid is preg-nancy category B because animal studies show noadverse effects, and less than 4% of the applied doseis systemically absorbed.4,12,15

Psoriasis and atopic dermatitisFor inflammatory skin conditions such as psoria-

sis, topical corticosteroids are considered first-linetherapy in pregnant patients. A detailed review ofpregnancy and psoriasis was performed by Tauscheret al17 in which they outlined a stepwise approachfor treatment. For localized disease in pregnancy,they recommended topical corticosteroids as first-line therapy followed by stepwise therapy withtopical calcipotriene, anthralin, and tacrolimus.1

Although all of these topical medications are cate-gory C, there are many data on corticosteroid use fora variety of medical conditions in pregnancy, so theyare currently the preferred first-line therapy.

The absorption, and therefore the safety in preg-nancy, of topical corticosteroids is related to a num-ber of factors, including the vehicle of administration,amount applied, occlusion, and sites of application.4

A practical approach to therapy with topical cortico-steroids in pregnant womenwould be to advise themnot to apply large amounts over extensive areas orunder occlusive dressings to avoid excessive

Table I. US Food and Drug Administrationpregnancy risk categories

Category Description

X Contraindicated in pregnancy; there is noreason to risk use of drug in pregnancy

D Positive evidence of risk to human fetus,but benefits may outweigh risks of drug

C Risk cannot be ruled out; human studies havenot been performed; animal studies may ormay not show risk; potential benefits mayjustify potential risk

B No risk to human fetus despite possible animalrisk; or no risk in animal studies and humanstudies not done

A Controlled studies show no fetal risk

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absorption16 because of certain studies that associatesuch use with a risk of low birth weight.12

In pregnancy, topical calcipotriene should beconsidered the next step in therapy for psoriasis.Topical calcipotriene is FDA pregnancy category C,and although skeletal abnormalities have occurred inanimal studies, no such findings have been shown inhuman beings.12 Practical usage limits and avoid-ance of occlusive dressings as described above fortopical steroids will likewise help avoid systemicabsorption and lower the risk of vitamin D toxicity. Ifboth topical steroids and calcipotriene fail, alterna-tive options for topical treatment are anthralin andtacrolimus.1 There are no studies on the use ofanthralin during pregnancy in human beings oranimals, but because there is also no evidence ofsystemic absorption after topical application, its useis not contraindicated.16 Likewise, data in humanbeings are limited for tacrolimus, but there havebeen no problems reported from topical use duringpregnancy.12,16 Both anthralin and tacrolimus arepregnancy category C, and until more data areavailable on their use in pregnancy, they remainthird- and fourth-line treatment options.

Pimecrolimus is a common topical treatment foratopic dermatitis. Similar to tacrolimus, it is a cate-gory C medication and no problems have beenreported from its use during pregnancy, but dataare limited.12 If topical corticosteroids fail, pimecro-limus would be an acceptable topical treatment foratopic dermatitis during pregnancy.

Topical antimicrobialsFor bacterial infections, topical antibiotics such as

mupirocin, neomycin, and polymyxin B are notassociated with teratogenicity.12 Large studies havenot been conducted on any of these, but they areconsidered safe to use during pregnancy.12

Topical antifungals are considered a safer alterna-tive to oral antifungals during pregnancy. Of theimidazoles, the 2 preferable options are clotrimazoleandoxiconazole,whicharebothcategoryB.4All othertopical imidazoles, including econazole and ketocon-azole, are category C because of limited data, but nospecific adverse effects from the use of these topicalimidazoles have been reported.12 Topical ciclopirox,naftifine, terbinafine, butenafine, and nystatin are allcategory B because there have been no problemsreported from topical use during pregnancy.12

Topical permethrin is the drug of choice forscabies and lice occurring in pregnancy and is poorlyabsorbed. It has been used extensively with minimaladverse effects reported, thus it is category B.12

SYSTEMIC MEDICATIONS DURINGPREGNANCY

Although systemic medications should only beusedwhen absolutely necessary during pregnancy, itis important to know the safety ratings of systemictreatments for common dermatologic conditions,especially for patients who may become pregnantduring the course of treatment or in circumstanceswhere delaying or interrupting treatment until preg-nancy is completed is not advisable. Table III sum-marizes the pregnancy classifications and risks ofeach systemic medication.

AcneAcne is a common condition that is generally

unaffected by pregnancy.1 The 2 most commonsystemic medications used to treat acne are antibi-otics and isotretinoin. Isotretinoin is category X andshould be avoided during pregnancy or in thosepatients trying to conceive.18 Increased fetal loss mayresult from first-trimester use, and specific malfor-mations including microtia, stenosis of the externalear canal, cleft palate, hydrocephalus, and cardiacoutflow tract defects may occur with use later inpregnancy.1 The risks of systemic retinoid exposureduring embryogenesis have been extensivelyreviewed, and a detailed discussion is beyond thescope of this review article. We would direct inter-ested readers to the included references.19-28

Tetracyclines are known to deposit in developingbones and teeth during the second and third trimester,resulting in enamel hypoplasia and a yellowish stain-ing of the teeth that will darken over time.12,29

Tetracyclines have also been associated with acutefatty liver of pregnancy, which is a potentially fatalsyndrome that occurs in the third trimester.4

Interestingly, tetracyclines have not been associatedwith congenital anomalies during the first trimester,12

so as long as they are discontinued as soon as

Table II. Pregnancy classifications and risks of topical medications for dermatologic therapy

Medication

Pregnancy

category High-risk period Risks/comments

RetinoidsTretinoin C First trimester Possible teratogen in first trimester, absorption

minimalAdapalene C First trimester Possible teratogen in first trimester, absorption

minimalTazarotene X Entire pregnancy Retinoid-like anomalies in animal studies

AntibacterialsClindamycin B NoneErythromycin B NoneMetronidazole B NoneDapsone C End of third trimester Theoretical risk of neonatal hyperbilirubinemia

if used near time of deliveryMupirocin B None No large studies availableNeomycin B None No large studies availablePolymyxin B B None No large studies available

Nonantibacterial antiacne productsSodium sulfacetamide C NoneBenzoyl peroxide C NoneSalicylic acid C None Do not apply over large areas under occlusive

dressings, 9-25% absorbedAzelaic acid B None \4% Absorbed

ImmunosuppressantsCorticosteroids C Third trimester with

high dosesPossible risk of low birth weight in some studieswith excessive absorption

Tacrolimus C None Data in human beings limitedPimecrolimus C None Data in human beings limited

AntipsoriaticsCalcipotriene C None Skeletal abnormalities in animal studies, no such

findings in human studiesAnthralin C None No evidence of systemic absorption, no studies

during pregnancy in human beings or animalsAntifungalsClotrimazole B NoneOxiconazole B NoneEconazole C None Limited dataKetoconazole C None Limited dataCiclopirox B NoneNaftifine B NoneTerbinafine B NoneButenafine B NoneNystatin B None

AntiparasiticPermethrin B None Has been used extensively in pregnancy

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pregnancy is suspected, there is very little risk.However, because of multiple concerns with useduring the second and third trimester, they are classi-fied as category D and should be avoided during laterpregnancy. Erythromycin is category B and is consid-ered safe in pregnancy; however, hepatotoxicity mayrarely occur with prolonged use of the erythromycinethylsuccinate formulation in pregnant patients.4 Inaddition, 2 Swedish studies have reported an in-creased risk of cardiovascular malformations when

erythromycin was used early in pregnancy.30,31

Alternative antibiotics in later pregnancy are azithro-mycin, penicillins, and cephalosporins, all of whichare pregnancy category B.5

Spironolactone, an antiandrogenic drug that com-petitively inhibits 5a-reductase and aldosterone, isoften prescribed off-label for acne.32 Pregnancycategory C, spironolactone caused feminization ofmale rat fetuses and delayed sexual maturation offemale rat fetuses in animal studies, but those effects

Table III. Pregnancy classifications and risks of systemic medications for dermatologic therapy

Medication

Pregnancy

category High-risk period Risks/comments

AntibioticsTetracyclines D Second and third

trimesterDental staining and enamel hypoplasia in secondand third trimester, has been associated withacute fatty liver of pregnancy

Erythromycin B First trimester Hepatotoxicity rare with prolonged use inpregnancy, possible increased risk ofcardiovascular malformations in earlypregnancy

Azithromycin B NonePenicillins B NoneCephalosporins B None

RetinoidsIsotretinoin X Entire pregnancy Increased fetal loss in first trimester, microtia,

external ear canal stenosis, cleft palate,hydrocephalus, cardiac outflow tract defects

Acitretin X Entire pregnancy Craniofacial, cardiac, thymic, and central nervoussystem malformations

Diuretic/antiandrogenicSpironolactone C After 8 wk Delayed sexual maturation of female rat fetuses

and feminization of male rat fetuses in animalstudies; risk to human fetus is only theoretical,as case reports show no adverse effects inhuman pregnancy

Antirheumatics/antimetabolitesMethotrexate X Entire pregnancy Increased risk of miscarriage, micrognathia,

developmental delays, craniosynostosis, smalllow-set ears, limb abnormalities, and growthretardation

Hydroxychloroquine C None Not associated with a specific congenitalmalformation

ImmunosuppressantsCyclosporine C None No specific birth defects, data on long-term

outcomes lackingCorticosteroids C Third trimester with

high dosesPotential for growth retardation and inhibitionof endogenous corticosteroid productionwhen used in high doses

Mycophenolate mofetil D Entire pregnancy Increased risk of miscarriage and anomalies ofdistal limbs, heart, esophagus, kidney, externalear, and face

PhototherapyBroadband ultraviolet Bphototherapy

- First 28 d of pregnancy Avoid overheating during therapy

BiologicsAdalimumab B None Limited dataEtanercept B None Limited dataInfliximab B None Limited data

AntihistaminesCetirizine B None Potential sedation of neonate in nursing mothersDiphenhydramine B None Potential sedation of neonate in nursing mothersLoratadine B None Potential sedation of neonate in nursing mothersChlorpheniramine B None Potential sedation of neonate in nursing mothers

AntifungalsTerbinafine B None Do not electively use to treat onychomycosis

during pregnancy per manufacturer

Continued

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Table III. Cont’d

Medication

Pregnancy

category High-risk period Risks/comments

Griseofulvin C Entire pregnancy Increased risk of skeletal and central nervoussystem anomalies and fetal loss

Ketoconazole C Entire pregnancy Sexual ambiguity of a male fetus, can interferewith pregnancy implantation

Itraconazole C None Lowest teratogenic potential of all imidazolesFluconazole C None Single-dose use confirmed safe

AntiparasiticIvermectin C None Teratogenic to animals in high doses

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have not been observed in human beings.1 Thedifferentiation of the urogenital tract does not occuruntil after 8 weeks, so any theoretical risk wouldoccur after that point,1 but 2 case reports of 5pregnancies where spironolactone was used by themother showed no abnormalities in the 2 female and3 male children.33,34

PsoriasisPsoriasis, a chronic inflammatory skin condition,

affects 2% to 3% of the population,35,36 and datashow that 44% of patients with psoriasis were femaleand of reproductive age.17 It is expected, then, thatall dermatologists will encounter pregnant patientsand patients of childbearing age with psoriasis.Approximately 50% of women with psoriasis willimprove during pregnancy, but it can worsen in upto 20%.1 Topical treatments are first-line therapy forpsoriasis, but systemic treatments may be requiredfor moderate to severe disease.

Oral retinoids, such as acitretin, that are used totreat psoriasis cause craniofacial, cardiac, thymic,and central nervous system malformations and arecontraindicated in pregnancy.16 Like all oral reti-noids, acitretin is a category X medication.

Methotrexate, a folic acid antagonist used to treatinflammatory skin disorders such as psoriasis, is alsoused as an abortifacient for conditions such asectopic pregnancy, so it is contraindicated in preg-nancy. Aside from an increased risk of miscarriage,associated malformations include micrognathia, de-velopmental delays, craniosynostosis, small low-setears, limb abnormalities, and prenatal growthretardation.37,38

Cyclosporine, a category C medication used formoderate to severe psoriasis, acts as a selectiveimmunosuppressant by inhibiting T lymphocytes.16

It has mainly been studied in pregnant organ trans-plant recipients, making it difficult to separate theeffects of cyclosporine from those of other medica-tions.16 No specific birth defect has been attributed tocyclosporine, but data on long-term outcomes are

lacking.4 For pregnant patients, its benefits outweighany theoretical risks, and it appears to be safe for thefetus.1

Broadband ultraviolet B phototherapy is consid-ered safe during pregnancy, with no adverse out-comes reported in studies.39,40 For extensivepsoriasis during pregnancy, this appears to be thesafest systemic therapy, but overheating duringtreatment should be avoided because of an increasedrisk of neural tube defects if hyperthermia occursduring neural tube formation in the first 28 days ofgestation.1,2

Data are currently limited on biologic agents suchas adalimumab, etanercept, and infliximab, but allare listed as pregnancy category B. Pregnancy reg-istries have been established for these medications,but given the limited data, the benefits of therapyshould be carefully weighed against any unknownrisk to the fetus.12 Currently, no specific congenitalmalformations have been attributed to any of theabove medications when used at any time during thepregnancy.

Atopic dermatitisFor atopic dermatitis during pregnancy, topical

medications should be prescribed initially, but theoccasional use of systemic steroids may be consid-ered in severe or refractory cases. Pregnancy cate-gory C, oral steroids appear to be safe when used inmoderate doses and for the shortest duration possi-ble.5 Some potential problems with high doses ofsystemic corticosteroid use during pregnancy in-clude intrauterine growth retardation and inhibitionof endogenous corticosteroid production.6,41-44

Some studies have shown an association betweenorofacial clefts and corticosteroid use in pregnancy,but a recent publication by Hviid and Molgaard-Nielsoen45 shows no such association. When facedwith a patient with a severe atopic dermatitis flare,either systemic corticosteroids or cyclosporinewould be acceptable choices, as neither is associatedwith an increase in congenital malformations when

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used in pregnancy for other conditions such asasthma and autoimmune disease.1

Mycophenolate mofetil, an immunosuppressiveagent used to treat moderate to severe refractoryatopic dermatitis, has been assigned a pregnancycategory D because of an increased rate of sponta-neous abortions and certain congenital malforma-tions including anomalies of the distal limbs, heart,esophagus, and kidney as well as external ear andfacial abnormalities such as cleft lip and palate.16

Mycophenolate mofetil should be avoided duringpregnancy and in women who are not activelypreventing pregnancy.

For conditions such as atopic dermatitis, antihis-tamines may be used for itching. Most antihista-mines, including cetirizine, diphenhydramine,loratadine, and chlorpheniramine are pregnancycategory B and are safe to use.12 It is important tonote that antihistamines should be avoided duringlactation in nursing mothers if possible because ofpossible sedating effects on the neonate.12

Connective tissue diseaseFor pregnant women with severe discoid lupus or

systemic lupus erythematous, the systemic medica-tion hydroxychloroquine is category C and has notbeen associated with a specific congenital malfor-mation. Because stopping hydroxychloroquine canprecipitate a lupus flare, most experts recommendcontinuing therapy if it is currently in use when apatient becomes pregnant.1 When faced with apatient with cutaneous lupus who is not at risk fora systemic flare and who is either pregnant or tryingfor pregnancy, short-term oral steroids along withtopical steroids may be a better treatment optionbecause more data are available regarding cortico-steroid use in pregnancy.

Fungal and parasitic infectionsFor fungal infections during pregnancy, oral an-

tifungals pose greater risks than topical agents.4 Thatsaid, terbinafine is a category B medication becauseof a low risk for fetal harm in animal studies and is thesystemic treatment of choice for a dermatophyteinfection during pregnancy. The manufacturer doesrecommend not using oral terbinafine electively totreat onychomycosis during pregnancy.12

The other major antifungals, griseofulvin and theimidazoles, are all pregnancy category C. In animalstudies, griseofulvin showed an increased risk ofskeletal and central nervous system anomalies andof fetal loss.1,4 Certain studies indicate an increasedrisk for conjoined twins aswell,1,12 so griseofulvin useduringpregnancy isnot recommended.Ketoconazolecan inhibit androgen synthesis, increasing the risk of

sexual ambiguity of a male fetus.1 It can also impairprogesterone secretion and interfere with early preg-nancy and implantation,4 so it should not be usedduringpregnancy. Thenewer imidazoles itraconazoleand fluconazole, both category C, have been thesubject of large cohort studies that indicate neither isteratogenic.1 Some studies suggest that fluconazoleshould be avoided in prolonged high doses to avoidthe risk of malformations, but multiple studies haveconfirmed the safety of a single oral dose, typicallyused by obstetricians to treat vaginal candidiasis.4,12

Itraconazole has the lowest teratogenic potentialbecause it has minimal effect on the steroidhormones.12

Finally, because it is teratogenic to animals in highdoses, thecategoryCmedication ivermectin shouldbeavoided as a treatment for scabies in lieu of permeth-rin, a safer topical FDA category B medication.12

DERMATOLOGIC SURGERY DURINGPREGNANCY

Most experts agree that nonemergent surgeryduring pregnancy be performed during the secondtrimester (weeks 13-24) or postpartum to avoid thepossible risk of spontaneous abortion in the firsttrimester or preterm labor in the third trimester.46 Ifpossible, the patient should be placed in the leftlateral position to avoid compression of the venacava by the pregnant uterus, but positioning on theright side is an acceptable alternative to avoid supinepositioning.46 Alcohol and chlorhexidine prepara-tions for the surgical site are acceptable to use duringpregnancy, but povidone-iodine absorption throughmucous membranes has been associated with fetalhypothyroidism.47-49 and hexachlorophene hasbeen reported to cause fetal central nervous systemtoxicity.47,48

Most dermatologic procedures can be performedusing local anesthetics. Lidocaine and prilocaine areboth category B medications, and multiple studieshave shown no increased risk of adverse effects inthe fetus.46 Local anesthetics do cross the placentalbarrier, but the only potential risk to the fetus wouldbe in the case of injection of excessive amounts orinadvertent arterial injection.50 Risks to the fetus inthat case would be central nervous system or cardiactoxicity.46 Local anesthetics such as mepivacaine andbupivacaine increase the risk of fetal bradycardia,51

so lidocaine and prilocaine would be the anestheticsof choice.

Epinephrine is often added to lidocaine in smallconcentrations as a vasoconstrictor to reduce bleed-ing at the operative site. It is a category C medicationbecause of decreased uterine blood flow with useduring animal experiments.46 Considering the

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dilution and small amounts used during dermato-logic procedures, potential risk is probably out-weighed by the benefits of decreased bleedingduring procedures, so epinephrine is consideredsafe when used judiciously.46

With regard to antibiotics and pain control, med-ications that are category A and B should be first-line.Antibiotics were previously discussed in the sectionon systemic medications. For pain control, aceta-minophen is category B and is first-line. Opioidnarcotic pain medications are all category C becauseof the risk of neonatal respiratory depression fromhigh doses used near the time of delivery and the riskof neonatal withdrawal from chronic maternal use.12

If opioids are necessary for pain control, they shouldbe used in the lowest dose and for the shortestpossible duration to avoid fetal withdrawal.1 Also,pain medications including nonsteroidal anti-inflammatory drugs should be avoided because ofthe risk of oligohydramnios and premature closureof the ductus arteriosis.1

Procedures such as cryotherapy, laser ablation,and application of trichloroacetic acid that involvelocal destruction of lesions without anesthetics aresafe to perform during pregnancy.1 Podofilox, 5-flu-orouracil cream, and interferon are not recommen-ded during pregnancy, however, because ofconcerns regarding maternal and fetal safety.1

SUMMARYWhen choosing treatments for dermatologic con-

ditions during pregnancy, a conservative approach isbest. Topical medications are first-line because theyare minimally absorbed, but certain oral medicationsare safe to use when topical therapy fails or is notpossible. Elective surgical procedures should bedelayed until the postpartum period, but whennecessary, dermatologic surgery during the secondtrimester using local anesthetics and proper patientpositioning may be performed.

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