Dr. Marcia Driscoll discusses treatment guidance for acne, psoriasis, melanoma, infections, and common dermatoses in the pregnant dermatology patient.
Marcia Driscoll, MD, is Associate Professor of Dermatology, University of Maryland School of Medicine.
“[The Pregnant Pause] has been a successful forum for a number of years, I believe, because all new physicians in general, outside of OB/GYN, perhaps feel a little bit uncomfortable with managing pregnant patients because… we have two people to worry about,” says Marcia Driscoll, MD, Associate Professor of Dermatology, University of Maryland School of Medicine, Baltimore, Maryland. “And we’re worried about not only managing the condition in the patient, but now what will be the effect [on the fetus] if we use medications.”
Dr. Driscoll, Director of the The Pregnant Pause: How to Evaluate and Treat your Pregnant Patients at AAD/VMX 2021, says five areas were discussed in the forum:
- Acne – by Jonette Keri, MD, PhD, University of Miami, Florida
- Psoraisis – by Bruce Strober, MD, PhD, Yale, New Haven, Connecticut
- Nevi and melanomas – by Jane Grant-Kels, MD, UConn Health, Farmington, Connecticut
- Infections – by Jenny Murase, MD, University of California, San Francisco
- Dermatoses of pregnancy – by Dr. Driscoll herself
Overall, each presenter addressed the things dermatologists need to keep in mind with pregnant patients and certain skin conditions, including special treatment considerations or limitations.
Treating Acne in Pregnant Patients
In terms of acne, Dr. Keri said safety data is lacking for about 80% of medications, in general, according to Dr. Driscoll. What is known is that benzoyl peroxide, topical erythromycin, topical azelaic acid, glycolic acid washes are safe for mild acne.
For more severe acne, oral amoxicillin and cyclosporine are safe.
If in doubt, particularly with oral medications, it is strongly advised to consult with the patient’s OB/GYN.
While retinoids are not typically used in pregnancy, Dr. Keri cited a study that showed inadvertent exposure to topical tretinoin in the first trimester does not affect the baby born to those women.
Treating Psoriasis in Pregnant Patients
Using topicals to treat small areas of psoriasis is safe in pregnant women because there is minimal absorption, according to Dr. Strober’s talk.
For more extensive psoriasis, narrow band UVB can be used, but because it degrades folic acid, additional folic acid supplementation may be necessary.
If systemic agents are necessary, TNF alfa inhibitors appear to be safe. Certolizumab, in particular, includes the polyethylene glycol molecule, which does not allow the drug to cross placenta.
There is some concern with other biologics crossing the placenta in third trimester. Use of these warrants a conversation with the patient’s OB/GYN.
Dr. Strober’s second choice is cyclosporine.
Treating Nevi and Melanoma in Pregnant Patients
It’s important to recognize that one-third of women who develop melanoma are women of child bearing age, says Dr. Driscoll. Dr. Grant-Kels discussed two myths:
- Myth #1 – It is normal for moles to change during pregnancy.
The reality is, any mole that changes during pregnancy should be biopsied, just as it would be in a nonpregnant patient. However, women with a history of atypical moles should be monitored more frequently during pregnancy. - Myth #2 – Women who develop melanoma during pregnancy have a poor prognosis.
Actually, pregnant women who are diagnosed with stage 1 melanoma have the same prognosis as their non-pregnant counterparts. “In the 1950s, they actually would propose terminating pregnancies in women that had melanoma, or even possibly sterilizing women that had atypical moles… and worried they may become pregnant,” said Dr. Driscoll. There isn’t enough data about prognosis for later stages of melanoma, however.
Treating Infections in Pregnant Patients
Dr. Murase discussed the safe treatment of infections and infestations in the pregnant patient by classes:
- Key anti-microbial agents include penicillins, 1st and 2nd generation cephalosporins, and erythromycin.
- The anti-viral agent aciclovir is safe.
- For anti-fungals, there is an overall concern with systemic agents. Some topicals, including azoles, are safe.
- For scabies, permethrin 5% and oral ivermectin are both safe.
Treating Dermatoses of Pregnancy
The most common dermatoses of pregnancy are atopic eruption (eczema or papular eruption) and polymorphous eruption in pregnancy (PEP). PEP, said Dr. Driscoll, is most common in first-time pregnancies. Both are pruritic. The mainstay of treatment are topical steroids or a short course of oral steroids may also be used. The antihistamines chlorpheniramine and diphenhydramine are also both safe to use during pregnancy.
