Patients who fall pregnant are usually aware that there are many things they are advised not to do while pregnant. They are aware that, during pregnancy, they should not drink alcohol, eat raw fish or fly in their third trimester. However, the day that the author had a new patient contact them to ask whether she could have her toxin topped up and purchase a 1% retinol cream before her baby was due, they realised that aesthetic practitioners have some educating to do.
Aesthetic practitioners and medical professionals are aware that injectables cannot be administered to pregnant patients. They are also aware that there are limitations to the ingredients that can be used in skincare products prescribed to these patients. However, the patients themselves are often in the dark about the fact that they will have to give up retinols and stronger systemic ingredients until after they finish breastfeeding.
Therefore, for patients expecting the ‘pregnancy glow’, the changes to their skin caused by pregnancy and the associated limitations for practitioners in regard to tools to treat these changes, can often come as a shock. In the author's 30 years of treating skin, unfortunately, this glow has been found to be a bit of a myth. This often impacts a patient's self-esteem, and when factoring in the emotional changes also associated with pregnancy, some patients can begin to look at this time as a negative experience in terms of more than just their skin. However, patients expect continuity of care from their providers, including their aesthetic practitioners. Medical practitioners have a duty of care, and it is, therefore, imperative for aesthetic practitioners with pregnant patients to understand how to treat the skin during this time period, while avoiding anything that has the potential to cause harm to the foetus.
» … during pregnancy, the increase in progesterone and oestrogen can directly contribute to an increase in pigmentation. Oestrogen in particular causes an increase of two things: melanocortin receptors (which cause melanocytes to become more inflammatory) and tyrosinase (which is an enzyme that contributes to pigment formation) «
To do this, it is important to note that a sharp increase in the hormones oestrogen and progesterone can trigger a range of conditions, such as acne, melasma, redness and dryness. Even patients who have never previously struggled with these conditions can experience one or more of them during pregnancy, meaning that it is advantageous to bring patients in for a skin consultation as soon as they discover they are pregnant. Each of these pregnancy-related skin conditions and how to treat them will be discussed in more detail.
Melasma
Primarily, many pregnant patients will experience melasma, which is so common during this time that it has become known as ‘the mask of pregnancy’ According to Handel et al (2014), approximately 40–50% of female patients with melasma have the condition as a result of pregnancy or the oral contraceptive. There are several contributors to this. First, during pregnancy, the increase in progesterone and oestrogen can directly contribute to an increase in pigmentation. Oestrogen in particular causes an increase of two things: melanocortin receptors (which cause melanocytes to become more inflammatory) and tyrosinase (which is an enzyme that contributes to pigment formation) (Kirsch, 2022). In fact, it is also known that the prevalence of melasma decreases significantly after 50 years of age, which is suggested to be linked to the reduction of these same hormones (progesterone and oestrogen), as a result of menopause and the resulting decrease in melanocyte activity (Handel et al, 2014)
When discussing quality of life for patients with melasma, Handel et al (2014) also say that patients…’ commonly report feelings of shame, low self-esteem, anhedonia, dissatisfaction and lack of motivation to go out. Suicidal ideas have also been reported in the literature’. This only further serves to illustrate the importance of contributing to a patient's positive experience with their skin during pregnancy (Handel et al, 2014).
Constant reassurance and education in general are important with these patients. They are often reassured when told their pigment can be more actively treated once breastfeeding is discontinued (if breastfeeding at all). However, in the meantime, the baby comes first.
When treating melasma, practitioners are limited, as they are not able to treat the condition directly with retinols or tretinoin, which is discussed further in the next section of this article. Skin-brightening vitamin C creams are frequently prescribed during pregnancy but, as this is not a cure for melasma, it is more important to consider prevention. A pregnancy-safe broad-spectrum sun protection factor (SPF) 50 topped up every 2 hours is paramount to prevent this condition from worsening.
Patients often say that they only have to spend ‘10 seconds’ in the sun and their melasma worsens! Therefore, education on proper sun protection, even when spending the day indoors or when it is cloudy, is key.
Acne
While acne is also very common during pregnancy, it is more easily treated than melasma. It is frequently triggered by an increase in progesterone specifically, as progesterone is linked to oil production. Furthermore, according to Tan et al (2018), ‘among the physiologic changes of pregnancy is a rise in serum androgen levels, which results in increased sebaceous gland activity and, often, worsening of the acne’. However, the same study also notes that ‘pregnancy and lactation are often part of the exclusion criteria in clinical trials, therefore, available information on medication-related teratogenicity and effects on lactation is often derived from case reports and animal studies’.
So, what can be used to safely treat acne during pregnancy? All systemic products must be avoided. This includes retinol, which is thought to cause birth defects. As explained by Bozzo et al (2011), ‘… there are four published case reports of birth defects in the literature associated with topical tretinoin use, which is consistent with retinoid embryopathy. The role of the topical retinoids in these cases remains controversial’.
However, the NHS states that benzoyl peroxide can be safely used in small quantities to treat acne during pregnancy (NHS, 2022). This is a powerful ingredient when treating acne and, therefore, should not be overlooked. Other pregnancy-safe ingredients to recommend to patients are azelaic acid to kill bacteria, sulphur or charcoal masks for decongestion, and citric and lactic acids for exfoliation. When many or all of these ingredients are combined into a safe, yet targeted, treatment plan, patients can often keep acne at bay during pregnancy. For example, an exfoliating cleanser, azelaic acid-based toner, oil-free moisturiser and SPF, combined with a decongesting charcoal mask 2–3 times a week, is often an effective enough routine to minimise acne until a new, stronger regime can be adopted post-breastfeeding.
Redness and dryness
The exact extent that the skin barrier and hydration are compromised during pregnancy is still unknown; however, according to Yang et al (2021), ‘approximately 60–80% of women first develop eczema during pregnancy, and over 50% experience skin deterioration’. The same study also explained that, ‘in normal pregnancy, the female body produces large amounts of oestrogen and progesterone … because of these changes during pregnancy, the skin becomes more sensitive and fragile due to increased sensitivity to external stimuli’.
Many patients report increased dryness and redness during pregnancy, as well as an increase in pre-existing conditions, such as eczema and rosacea. Hydration that would often nourish the skin is somewhat redirected towards the growing foetus, leaving the skin to feel parched. Additionally, rosacea in particular is likely to be worsened in pregnancy due to an increase in blood flow to the area.
So, how can these symptoms be addressed while, again, avoiding systemic skincare ingredients? It is much easier to comfort the skin during pregnancy than actively treat skin conditions. Ceramides are crucial for this, along with hyaluronic acid to hydrate the skin. It can also be helpful to recommend a cooling/calming hydration mist throughout the day. This is more of a comforting product rather than a treatment to address a skin concern, but it often helps to make patients feel more comfortable while simultaneously helping the skin to retain moisture.
Conclusion
In conclusion, as aesthetic practitioners, it is important to deliver continuity of care to pregnant patients and provide them with help via information and topical cosmeceuticals. The above conditions are likely to occur during pregnancy and may lead to a negative experience if not properly handled. Practitioners can manage this and ensure pregnancy is as positive an experience as possible for patients when it comes to their skin and that ever-elusive ‘pregnancy glow’.