Managing Acne in Pregnancy: A Review of First- and Second-Line Treatments

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, we’ll hear about the management of acne in pregnant patients from Dr. Jenny Murase. She’s the Director of Medical Consultative Dermatology for the Palo Alto Foundation Medical Group and an Associate Clinical Professor at the University of California, San Francisco. Here’s Dr. Murase now.

Dr. Murase:
Acne is one of the most common conditions that dermatologists will see during pregnancy because we care for so many chronic inflammatory skin conditions, and acne is one of the most common that we see. And severe acne during pregnancy is actually generally fairly uncommon. The severity of facial acne, truncal acne, and hirsutism is higher in the third trimester compared to other trimesters.

So classically, azelaic acid, clindamycin, erythromycin, and metronidazole were all previously category B as designated by the USFDA, and then topical benzoyl peroxide, salicylic acid, and dapsone were considered category C. Now, when dermatologists see that category designation, I think oftentimes it’s confusing because medicines like benzoyl peroxide that have been around for a very long time and stood the test of time are over the counter. And they wouldn’t make anything that’s teratogenic an over-the-counter medication, obviously, just like the salicylic acid washes that people use. So that’s why a medicine like salicylic acid, which you’re applying topically in this situation, is perfectly safe, but it would be labeled C because if you give acetylsalicylic acid, it’s been known to bind platelets or cause Reye syndrome at high doses that are used, and so the B and C designation is very misleading, especially for medicines that have been around for a long time and stood the test of time. So I think it’s important for dermatologists to know and reassure their patients and be aware of the safety data and how to appropriately counsel.

We did develop an article in the Journal of American Academy of Dermatology that was published in October 2024 that provided information regarding the safety of medicines—all the topical and oral medicines that we use in our field—and so that is a good reference to make sure that patients are getting the appropriate counseling information. But in general, the topical therapies—as a group for treatment of acne vulgaris and acne rosacea in pregnancy—are considered safe.

I think that oral antibiotics tend to be our go-to for patients that are failing the topical treatments. So in acne vulgaris patients, I tend to use third-generation cephalosporins, like cefadroxil, for example, or certainly, you could use first-generation cephalexin. For an acne rosacea patient, I tend to favor amoxicillin. I feel that the macrolide class of antibiotics, including azithromycin and erythromycin, really should be considered second line because there is an association with pyloric stenosis as well as a congenital heart malformation. It’s a slight increased risk, but it’s still enough that I feel like it should be a second-line therapy. Erythromycin estolate has been associated with hepatotoxicity in about 10‒15 percent of patients with prolonged use, so we don’t use this variant in the United States. We use erythromycin base or erythromycin ethylsuccinate that don’t have that associated hepatotoxicity risk. And then for breastfeeding women, there is an increased risk of pyloric stenosis with exposure both during pregnancy but also in those first three months of life with erythromycin, so that’s why I consider it to be a second-line therapy.  

Announcer:
That was Dr. Jenny Murase discussing how we can manage acne in pregnant patients. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!