Acne in pregnancy:
what is avoided, what is generally used, and what waits

Why does acne appear or worsen in pregnancy?

Pregnancy raises androgens and progesterone, both of which increase sebaceous gland activity, and in the first trimester that shift is steep. The result for many women is acne that starts, returns after years of clear skin, or worsens, often on the lower face and jaw and sometimes on the chest and back. For some it settles in the second or third trimester as hormone levels plateau; for others it persists until after delivery, and a few see it only after birth. A history of acne before pregnancy, or acne that flares before periods, makes a pregnancy flare more likely.

The acne itself is ordinary acne: the same four drivers of sebum, follicle blockage, Cutibacterium acnes and inflammation set out on acne treatment Singapore. What changes is the treatment, because the standard ladder contains medicines that are avoided when a baby is developing or feeding, and because elective procedures are deferred. Pregnancy also changes the skin around the acne: melasma often appears or darkens, the skin may be more sensitive, and marks left by inflammation can pigment more readily, which is one reason gentle control is still worthwhile rather than simply waiting.

Two questions settled early

• Is it acne? Pregnancy-related itchy rashes and folliculitis can look similar and are managed differently; the pattern is checked at examination.
• Is anything currently being used that should stop? A retinoid, a tetracycline or spironolactone started before the pregnancy was known is the first thing to review with the obstetrician.

Which acne treatments are avoided in pregnancy and breastfeeding?

The treatments below are avoided or restricted in pregnancy on the basis of known harm, biological plausibility or absence of safety data. The default where evidence is absent is to wait, because acne is not an emergency and nothing elective justifies an unknown risk to a pregnancy. The table reflects the American Academy of Dermatology's acne guideline and public guidance, the American College of Obstetricians and Gynecologists' guidance on skin conditions in pregnancy, and the published reviews of acne treatment in pregnancy and lactation; the obstetrician's advice for any individual pregnancy takes precedence over all of it.

Two notes on the retinoid row. A cosmetic retinol bought over the counter is a retinoid and is stopped in pregnancy and when trying to conceive, not only prescription tretinoin. And exposure to a topical retinoid before a pregnancy was known is a reason to tell the obstetrician, not a reason for alarm, because absorption through the skin is low; the precaution exists so that the question never has to be asked.

“In pregnancy I treat the acne I can treat safely and I plan the rest. The obstetrician decides what goes on the skin; I decide what order the work happens in afterwards.”

Dr Sin YongOn acne in pregnancy

What is generally used for acne in pregnancy?

A small number of treatments are generally regarded as reasonable in pregnancy, and they are enough for most pregnancy acne, which is usually mild to moderate. Each is used after the obstetrician has been asked, on the smallest area and at the lowest strength that works, and the routine around them is kept simple.

Light-based treatment occupies a middle ground. Public guidance from the American Academy of Dermatology describes lasers as relatively safe in pregnancy with a dermatologist's assessment, while the broader position on elective aesthetic lasers is to wait. At this practice elective laser work for acne is deferred during pregnancy, since medical control is usually sufficient and the reasoning for deferring elective treatment applies. Where acne is severe and distressing, the decision is made with the obstetrician and, where needed, a dermatologist.

Picking and squeezing are discouraged as firmly as in any other acne, because the marks that follow pigment more readily in pregnancy and the pigment-lightening agents that would usually treat them are among the things avoided.

Which procedures are deferred until after pregnancy?

Elective aesthetic procedures are deferred in pregnancy because their safety in pregnant women has not been studied, nothing about them is urgent, and the skin and face are changing anyway. The acne-related procedures that wait are set out below, with what is done meanwhile.

Deferral is not neglect. The plan is made during pregnancy, which is a good time for it: the acne is graded, look-alikes are excluded, the routine is simplified, any marks or early scars are mapped, and the order of work after delivery is agreed, so that nothing is lost to waiting. The acne-to-scar pathway describes that order, and it does not change because the first stage happened during a pregnancy.

What changes while breastfeeding?

Breastfeeding is a different question from pregnancy, and usually a less restrictive one, but the default remains to ask before using anything. The question for each medicine is whether a meaningful amount reaches the milk and whether it matters to the infant. The published reviews of acne treatment in lactation and the current acne guideline draw broadly the same lines.

Generally regarded as compatible, after advice

• Azelaic acid, benzoyl peroxide and topical clindamycin or erythromycin on limited areas, applied away from the breast and washed from the hands
• Low-strength glycolic acid on small areas
• Short courses of oral penicillins, cephalosporins or erythromycin where the doctor judges them necessary

Avoided or deferred

• Oral isotretinoin, throughout breastfeeding
• Prolonged oral tetracycline courses; short courses are a doctor's decision
• Topical retinoids and cosmetic retinol, usually deferred until feeding has finished, on the doctor's advice
• Spironolactone and other hormonal options, decided with the doctor
• Hydroquinone and high-strength peels

Elective procedures remain deferred for many women while breastfeeding, particularly injectables and heating devices, while some are assessed individually. Dr Sin Yong's general position on treatments in breastfeeding is set out on the pregnancy and breastfeeding page. Two practical points: anything applied to the chest is kept well away from the nipple and areola, and the postpartum months bring their own skin changes, including shedding hair and persisting melasma, which are assessed in the same visit rather than treated piecemeal. The post-pregnancy stretch marks page and the melasma page cover the two most common companions of postpartum acne.

Why the obstetrician decides first, and how the plan is made here

Every decision about a medicine in pregnancy is made with the doctor who is responsible for the pregnancy. Dr Sin Yong does not prescribe for a pregnant patient over the obstetrician's advice, and where the two have not spoken, the first step is a note or a call. That is not caution for its own sake; the obstetrician knows the history of the pregnancy, any complications, and the other medicines in use, and an acne plan has to fit around all of it. Where acne is severe enough to need oral treatment, a dermatologist may be involved as well.

What a consultation during pregnancy covers

1. Confirmation that it is acne, and grading
2. Review of everything currently applied or taken, with anything on the avoided list stopped and reported to the obstetrician
3. A simple routine: mild cleanser, plain moisturiser, broad-spectrum sunscreen, and one or two topical agents from the generally-used list once the obstetrician has agreed
4. Mapping of marks and any early scars, so the postpartum sequence is ready
5. Advice on what to do about a painful cyst, and when to get in touch
6. A plan for after delivery and after breastfeeding, when the full pathway resumes

What decides the plan

• Trimester, and the obstetrician's view of the pregnancy
• Grade of acne and how much it is affecting the person
• What was being used before the pregnancy was known
• Skin type and pigment risk, since marks are managed with fewer tools
• Whether breastfeeding is planned, which shapes the timing of the postpartum plan

Aftercare in broad terms is the same simple routine kept up, sun protection every day, no picking, and a review after delivery. Consultations are described under how consultations work; a planning consultation during pregnancy is welcome, and no procedure is booked from it.