Acne Treatment During Pregnancy and Lactation: Safe Therapies, Barrier Care, and Practice Guidance

Conclusions

• Acne is common during pregnancy, usually mild, and tends to worsen in the third trimester, especially truncal acne.
• Severity is harder to predict from prior pregnancies or pre-pregnancy acne, but PCOS, irregular menses, hirsutism, and higher BMI are associated with worse acne.
• Management should start with expectation setting, attention to the patient’s overall health before conception, and treatment decisions tailored to trimester and severity.
• Topical therapies are the foundation of treatment, with azelaic acid, clindamycin, erythromycin, benzoyl peroxide, and low-strength salicylic acid generally favored when used appropriately.
• Topical dapsone and clascoterone have limited pregnancy or breastfeeding safety data, so they should be used cautiously or avoided.
• Topical retinoids appear more reassuring than historically believed, especially adapalene, but most experts still avoid retinoids with the greatest concern in pregnancy.
• Patients should also be warned that online acne supplements may contain teratogenic amounts of vitamin A.
• Myo-inositol appears to be a safe adjunct that may improve acne and PCOS-related metabolic features and may have additional pregnancy benefits.
• For more severe acne, systemic options such as zinc, certain beta-lactams, and azithromycin can be used, with erythromycin estolate avoided.
• Prednisone can be used for severe, scarring acne in pregnancy when needed, ideally with obstetric input.
• Phototherapy, especially narrow-band UVB and 308-nm excimer light, may be useful and appears safe, but folate supplementation should be considered.
• Certain cosmetic procedures, including glycolic or lactic acid peels and low-dose intralesional corticosteroid injections, can be reasonable adjuncts in pregnancy.
• Overwashing can worsen acne by impairing skin barrier function, so gentle cleansing is preferred.
• Because acne can cause substantial psychological distress, pregnant patients who desire treatment should generally be offered care, and referral is appropriate when expertise is limited.
• During lactation, medication safety should be checked with pediatric guidance, and treatment choices should remain individualized and conservative.