treatment of acne in the pregnant patient muanda ft, sheehy o, berard a. use of antibiotics during...
TRANSCRIPT
![Page 1: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/1.jpg)
Treatment of Acne in the Pregnant Patient
Jonette E. Keri, M.D., Ph.D.Associate Professor of Dermatology, University of
Miami, Miller School of Medicine Chief, Dermatology Service, Miami VA Hospital
![Page 2: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/2.jpg)
Disclosures
• Hoffman-La Roche
![Page 3: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/3.jpg)
Outline
• Why treat during this time• Medications and Therapies that can be used• Plan for your practice• What if…
![Page 4: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/4.jpg)
Acne
• Acne is a common problem• Post-adolescent acne is more common in women• Acne is commonly seen in pregnant women• Causes significant psychological stress
![Page 5: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/5.jpg)
How common is acne in pregnancy?
• Difficult to find consistent numbers• Many references say common
![Page 6: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/6.jpg)
How Common is Acne in Pregnancy?
• 400 women surveyed
• 75% Better after delivery• 13% No change• 12% Got worse
• Nussbaum, R. Clin Derm 2006; 24:133-141
![Page 7: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/7.jpg)
How do we treat these patients?
• Get their acne as good as you can before they start to try to conceive
• Encourage them to get in the best health they can be prior to trying to conceive
• Discuss their expectations with them
![Page 8: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/8.jpg)
How do we treat these patients?
• Topicals first• Systemics second line
![Page 9: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/9.jpg)
Topical Medications
• Over the counter or prescription?
• Most times by the time the patient comes to see you they have tried the over the counter medications AND they are looking for something more
• This is an important time to discuss expectations
![Page 10: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/10.jpg)
Pregnancy Categories
• I discuss the old Food and Drug Administration (FDA) pregnancy categories
• I do this during the expectation discussion
![Page 11: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/11.jpg)
Risk Classifications
• United States Food and Drug Administration (FDA)• New guidelines approved but still to be implemented for older drugs
(drugs approved prior to June 30, 2015)
• There are other rating systems• Australian • Swedish• German
![Page 12: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/12.jpg)
Old FDA pregnancy categories - simplified
• A = Safety established in human studies• B = Presumed safety based on animal studies• C = Uncertain safety; no human studies and animal studies show
adverse effect• D= Unsafe - evidence of risk that may in certain clinic circumstances
be justifiable• X = Highly unsafe – risk of use outweighs any possible benefit
![Page 13: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/13.jpg)
New FDA Labeling• New Pregnancy and Lactation Labeling Rule (PLLR)• The new rule for newly approved prescription
medications• Staggered phase-in for older prescription drugs
• Danish MJ, Murase JE. The new US Food and Drug Administration pregnancy and lactation labeling rules: Their impact on clinical practice. J Am Acad Dermatol. 2015 Aug;73(2):310-1.
![Page 14: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/14.jpg)
New FDA labeling
• Pregnancy• Lactation (instead of Breast-feeding)• Females and Males of Reproductive Potential – NEW
• Danish MJ, Murase JE. The new US Food and Drug Administration pregnancy and lactation labeling rules: Their impact on clinical practice. J Am Acad Dermatol. 2015 Aug;73(2):310-1.
![Page 15: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/15.jpg)
Topical Medications for Acne
![Page 16: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/16.jpg)
Topical medications Category B versus Category C• Generally use category B medications• Topicals
• Azeleic Acid• Clindamycin• Erythromycin
• Metronidazole
![Page 17: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/17.jpg)
How about the topical category C medications?• Benzoyl Peroxide• Salicylic Acid• Dapsone (topically)
![Page 18: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/18.jpg)
Benzoyl Peroxide
• Benzoyl Peroxide• Most feel safe for use• Systemic Absorption is minimal• Over the counter preparations have no pregnancy warning• Benzoyl Peroxide is metabolized to benzoic acid (a food additive) in the skin*
*reviewed in: Murase JE, Heller MM, Butler DC. Safety of dermatologic medications in pregnancy and lactation: Part I. Pregnancy J Am Acad Dermatol. 2014 Mar;70(3):401.e1-14; quiz 415.
![Page 19: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/19.jpg)
Salicylic Acid
• Salicylic acid • Category C• Likely safe• Systemic absorption minimal over small areas• Low dose aspirin used for the treatment of pre-eclampsia in women*• Key point – concentration should be low and over limited body surface areas
• *Trivedi, N.A., J. Postgrad Med. 2011:57(2):91-5.
![Page 20: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/20.jpg)
Dapsone - topical
• Dapsone • Category C• Likely safe but studies are lacking• Oral dapsone is used to treat dermatitis herpetiformis in pregnancy
• *Tuffanelli, DL. Ach Dermatol 1982;118(11):876.
![Page 21: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/21.jpg)
Topical Retinoids
• Tretinoin – Category C• One case report of otocerebral anomalies*
• Adapalene – Category C• One case report of anophthalmia and agenesis of the optic chiasma**
• Tazarotene – Category X• Contraindicated in pregnancy• *Selcert, D. Otocerebral anomalies associated with topical tretinoin use. Brain Dev. 2000;22(4):218-20.• **Autret E. et al. Lancet 1997;350(9074):339.
![Page 22: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/22.jpg)
Category N (Not Classified) Topical
• Glycolic Acid – best example and most well received
![Page 23: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/23.jpg)
Glycolic Acid
• Glycolic Acid• Thought to be safe as only a minimal amount is absorbed
• Category - N• Up to 27% absorbed into the skin depending on pH, concentration and time*
(in vitro)• Rats have some adverse reproductive effects, but the doses were much larger
than used in humans, (300-600mg/kg/d orally)**
*Kraeling, MK, et al. In vitro percutaneous absorption of the alpha hydroxy acids in human skin J Soc Cosmet Chem 1997; 48:187-97.
** Munley, SM, etal. Developmental toxicity study of glycolic acid in rats. Drugs Chem Toxicol 1999;22(4):569-82
![Page 24: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/24.jpg)
Systemic Medications
![Page 25: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/25.jpg)
Systemic Medications – Category A
• Zinc supplements • Generally recommended 30-200mg a day • Gastrointestinal disturbances• 75mg/day of elemental zinc show no harm to the fetus*• Watch “overdose” – can lead to hypocupremia
*Dreno, B. Ann Dermatol Venereol. 2008;135(1):27-33.
![Page 26: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/26.jpg)
Systemic Medications – Category B
• Cephalexin• Cefadroxil ** Severe acne patient• Amoxicillin ** Severe rosacea patient• Azithromycin• Erythromycin
• AVOID Erythromycin Estolate – can be associated with hepatotoxicity in 10-15% of pregnant patients with prolonged use*
• Unable to order/prescribe Estolate• Rare cases of pyloric stenosis in infants with other forms of erythromycin*Hale, E.K., Int J Dermatol 2002; 41:197-203**Reviewed in: Murase JE, Heller MM, Butler DC. Safety of dermatologic medications in pregnancy and lactation: Part I.
Pregnancy J Am Acad Dermatol. 2014 Mar;70(3):401.e1-14; quiz 415.
![Page 27: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/27.jpg)
Systemic Medications - Category C
• Prednisone when the patient has severe acne/scarring • Work with the Ob/Gyn • Dosing?
• 0.5mg/kg or less in most cases• Weeks to months – duration• Combine with systemic antibiotic• Bone and Gastrointestinal prophylaxis• Work with Ob/Gyn
![Page 28: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/28.jpg)
So in practice how do we decide?
• Discuss expectations with the patient• First grade the acne – your grading system
• Mild• Moderate• Severe – Look for scarring
• If acne is moderated to severe consider systemic medications• Document discussions
![Page 29: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/29.jpg)
Regimen
• Mild non-abrasive washes • Washes with Glycolic Acid • Topical Azeleic acid • Topical Clindamycin• Oral Antibiotics
• Physical sunscreen
![Page 30: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/30.jpg)
Over the Counter Controversies
• Benzoyl Peroxide or not?• Salicylic Acid as a wash or not?
• Depends on the patient• Many patients are very conservative
• Over the counter washes listed above are safe
![Page 31: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/31.jpg)
What do I do?
• Talk to the OB/GYN• Don’t be afraid to ask for help• Consider prednisone in the severe patient
![Page 32: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/32.jpg)
Is ThereAnything New?
![Page 33: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/33.jpg)
Maybe not new, but not discussed in the past with respect to acne
• nbUVB• Watch folate levels
![Page 34: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/34.jpg)
Narrow band UVB for acne
• Pregnant patients• Safe
• Zeichner, J. Narrow band UVB therapy for the treatment of acne vulgaris in pregnancy. Arch Derm 2011 147: (5); 537.
![Page 35: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/35.jpg)
Folate reduction associated with nbUVB
• Studies using narrowband UVB showed mixed results, potentially explained by dose-dependent degradation of folate;
• Exposure >40 J/cm2 cumulatively and >2 J/cm2 per treatment were associated with 19%-27% decreases in serum folate levels, while lower doses did not affect folate levels.
• There is no evidence of decreased folate levels after UVA exposure.• A lot of variability• Zhang M, Goyert G, Lim HW. Folate and phototherapy: What should we inform our patients? J Am Acad Dermatol. 2017 Nov;77(5):958-964.
![Page 36: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/36.jpg)
Folate supplementation in nbUVB patients
Recommend all women of childbearing age on phototherapy take 0.8 mg/day of folate supplements, as suggested by current guidelines for women of childbearing age, to reduce the risk of neural tube defects in unplanned pregnancy.
• Zhang M, Goyert G, Lim HW. Folate and phototherapy: What should we inform our patients? J Am Acad Dermatol. 2017 Nov;77(5):958-964.
![Page 37: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/37.jpg)
Anything else new?
![Page 38: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/38.jpg)
Case report using oral metronidazole along with prednisone for significant acne in pregnancy
• 30 year old woman• 14 weeks gestation had significant acne • treated with prednisone and then a variety of oral antibiotics
including amoxicillin, erythromycin and cephalexin• Initially got better but then got more acne, presumed steroid acne
over the trunk and her prednisone dose was lowered and her erythromycin dose was increased
• Patient improved some and then was switched to metronidazole (?) 250mg twice daily and did well, but this was at 28 weeks
• Awan SZ, Lu J. Management of severe acne during pregnancy: A case report and review of the literature. Int J Womens Dermatol. 2017 Jul 13;3(3):145-150.
![Page 39: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/39.jpg)
Why do I bring up the gestational age?
• Recent review in Canada of data in Quebec Canada from (1998-2009).• Looked at spontaneous abortions (<20 weeks) in patients taking antibiotics• Found macrolides (excluding erythromycin), quinolones, tetracyclines,
sulfonamides and metronidazole during early pregnancy were associated with an increased risk of spontaneous abortion.
• However, residual confounding by severity of infection cannot be ruled out.
• They found cephalexin, amoxicillin, erythromycin to be safe• Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633.
12
![Page 40: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/40.jpg)
Cosmetic procedures - peeling
• Glycolic acid peels: Relatively safe, limited dermal penetration.
• Lactic acid peels: Reports of safe use for gestational acne, limited dermal penetration.
• (Salicylic acid peels: Pregnancy category C, significant dermal penetration, limit use to small areas of coverage.) – Caution
• Reviewed in: Trivedi MK1,2, Kroumpouzos G3,4, Murase JE1,5 A review of the safety of cosmetic procedures during pregnancy and lactation. Int J Womens Dermatol. 2017 Feb 27;3(1):6-10.
![Page 41: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/41.jpg)
What if.....??The patient had an exposure….
![Page 42: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/42.jpg)
Topical Retinoid Exposure
• The objective:• Does exposure to topical retinoids lead to an increase in the risk of
adverse pregnancy outcome
• Searched Medline, Embase, Web of Science and Cochrane Central Register of Controlled Trials databases from inception to 4 December 2014
• Kaplan YC, et al. Pregnancy outcomes following first-trimester exposure to topical retinoids: a systematic review and meta-analysis. Br J Dermatol. 2015 Nov;173(5):1132-41
![Page 43: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/43.jpg)
Topical Retinoid Exposure• Meta-analysis• 654 pregnant women• 1375 unexposed control pregnant women• No significant differences among the studies evaluated
• Did not detect significant increases in:• congenital malformations • spontaneous abortions • stillbirth• elective termination of pregnancy • low birthweight • prematurity
• Kaplan YC, et al. Pregnancy outcomes following first-trimester exposure to topical retinoids: a systematic review and meta-analysis. Br J Dermatol. 2015 Nov;173(5):1132-41
![Page 44: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/44.jpg)
What does this tell us?
• Use this result primarily to reassure women who may have had an inadvertent exposure.
• But…. there is not enough evidence (statistical power) to justify the use of topical retinoids during pregnancy.
• Kaplan YC, et al. Pregnancy outcomes following first-trimester exposure to topical retinoids: a systematic review and meta-analysis. Br J Dermatol. 2015 Nov;173(5):1132-41
![Page 45: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/45.jpg)
Sulfonamide exposure
• Sulfonamide antibacterials are widely used in pregnancy, but evidence about their safety is mixed
• The objective of this study was to assess the association between first-trimester sulfonamide exposure and risk of specific congenital malformations
• Hansen C, Andrade S, Freiman H et al. Pharmacoepidemiol Drug Saf. 2016 Feb;25(2):170-8.
![Page 46: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/46.jpg)
Sulfonamide Exposure• METHODS: • Mother-infant pairs were selected from a cohort of
1.2 million live-born deliveries (2001-2008) at 11 US health plans comprising the Medication Exposure in Pregnancy Risk Evaluation Program.
• Hansen C, Andrade S, Freiman H et al. Pharmacoepidemiol Drug Saf. 2016 Feb;25(2):170-8.
![Page 47: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/47.jpg)
Sulfonamide Exposure• METHODS: • Mothers with first-trimester trimethoprim-
sulfonamide (TMP-SUL) exposures were randomly matched 1:1 to:
• a primary comparison group (mothers exposed to penicillins and/or cephalosporins)
• a secondary comparison group (mothers with no dispensing of an antibacterial, antiprotozoal, or antimalarial medication)
• Hansen C, Andrade S, Freiman H et al. Pharmacoepidemiol Drug Saf. 2016 Feb;25(2):170-8.
![Page 48: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/48.jpg)
Sulfonamide Exposure• Overall, cardiovascular defects (1.52%) were the most
common and cleft lip/palate (0.10%) the least common that were evaluated.
• TMP-SUL exposure was NOT associated with statistically significant elevated risks for:
• Cardiovascular defects• Cleft lip/palate• Clubfoot• Urinary system defects
Hansen C, Andrade S, Freiman H et al. Pharmacoepidemiol Drug Saf. 2016 Feb;25(2):170-8.
![Page 49: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/49.jpg)
Sulfonamide Exposure
• CONCLUSIONS:
• First-trimester TMP-SUL exposure was not associated with a higher risk of the congenital anomalies studied, compared with exposure to penicillins and/or cephalosporins, or no exposure to antibacterials
• Hansen C, Andrade S, Freiman H et al. Pharmacoepidemiol Drug Saf. 2016 Feb;25(2):170-8.
![Page 50: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/50.jpg)
After pregnancy, then what?
•LACTATION
PEARL:Ask the Pediatrician• American Academy of Pediatrics (AAP) has guidelines
![Page 51: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/51.jpg)
AAP guidelines for medications prescribed to lactating mothers • Medications divided into 3 groups
1) Generally compatible with breastfeeding2) May be of concern3) Used with concern
![Page 52: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/52.jpg)
Conclusions
• Define expectations• Document discussions• Don’t be afraid to treat• Don’t be afraid to ask for help
• OB/GYN• Pediatrician • Other Dermatologists
![Page 53: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/53.jpg)
Treating Acne During Pregnancy and Lactation
• Editorial• Significant psychological burden during these times (pregnant and
post-partum periods)• New FDA labeling may help after some initial “getting used to…”• All pregnancies have a background risk of loss, birth defect, or
adverse event
• Baldwin HE. Treating acne during pregnancy and lactation. Cutis. 2015 Jul;96(1):11-2
![Page 54: Treatment of Acne in the Pregnant Patient Muanda FT, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May 1; 189(17): E625–E633](https://reader035.vdocuments.site/reader035/viewer/2022070608/5ab096897f8b9ac3348b5719/html5/thumbnails/54.jpg)
Thank you!