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Presentation

Pregnancy-Safe Treatment of Infectious Dermatoses: Bacterial, Fungal, Viral, and Parasitic Infections

Description

The talk reviewed pregnancy-safe treatment options for common infectious dermatoses and emphasized that clinicians should proactively ask about pregnancy because many patients do not disclose it before medication exposure. It was organized into bacterial, fungal, viral, and parasitic infestations. For bacterial infections, topical agents are considered safe, and oral first-line options include penicillins, first-generation cephalosporins, and dicloxacillin; clindamycin is preferred for MRSA when needed, while abscesses should primarily be managed with incision and drainage. It also discussed antibiotic cautions: erythromycin is preferred among macrolides, sulfonamides should be avoided near delivery, trimethoprim-sulfamethoxazole needs folic acid supplementation in the first trimester, tetracyclines are contraindicated after 15 weeks, and quinolones are generally avoided unless necessary. For fungal disease, topical azoles, nystatin, gentian violet, selenium sulfide, zinc pyrithione, and limited benzoyl peroxide were described as safe, while systemic azoles and griseofulvin are generally not recommended; oral terbinafine may be used selectively when benefits outweigh risks. For viral infections, oral antivirals such as acyclovir, valacyclovir, and famciclovir were described as very safe, with recommended treatment of primary HSV and suppressive therapy starting at 36 weeks for vaginal delivery planning. For HPV and warts, destructive or non-drug approaches like liquid nitrogen, trichloroacetic acid, squaric acid, and salicylic acid were favored, while podofilox, cantharidin, imiquimod, and podophyllin were discouraged. For scabies and lice, permethrin was the mainstay, with sulfur, aloe vera, and occasionally ivermectin as alternatives; lindane and malathion should be avoided. The talk concluded that most oral antifungals are unsafe, most oral antivirals are safe, and pregnancy management should prioritize avoiding unnecessary medication while using evidence-based therapies when treatment is required.

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Conclusions

Pregnant patients with common skin infections can often be treated safely, but therapy should be chosen conservatively and guided by culture and sensitivity when possible.
For bacterial infections, topical agents are preferred when adequate, and pregnancy-compatible oral options include penicillins, first-generation cephalosporins, dicloxacillin, and clindamycin.
Abscesses in pregnancy should generally be managed with incision and drainage rather than antibiotics unless size or surrounding cellulitis warrants additional treatment.
Macrolides, rifampin, sulfonamides, and trimethoprim-sulfamethoxazole can be used selectively in pregnancy, but each has trimester-specific cautions and fetal risks that limit routine use.
Quinolones and tetracyclines are not first-line in pregnancy, and tetracyclines should be avoided after the first trimester because of fetal bone and tooth effects.
Most topical antifungals for tinea and candidiasis appear safe in pregnancy, while systemic azole antifungals and griseofulvin are generally avoided because of teratogenic concerns.
Oral terbinafine appears reassuring in large observational data, but systemic antifungal use in pregnancy is still usually reserved for special circumstances.
Oral antivirals for herpes, especially acyclovir, are considered very safe in pregnancy and should be used to treat primary infection and symptomatic recurrences.
HPV-related warts in pregnancy are best managed with destructive or non-systemic approaches such as liquid nitrogen or trichloroacetic acid, while podophyllin, podofilox, imiquimod, and cantharidin should be avoided or used with great caution.
For scabies and lice, non-systemic or topical approaches are preferred, with permethrin as a key option for scabies and occlusive therapy or limited topical pediculicides for lice.
Overall, the main clinical message is that many infectious dermatoses in pregnancy have effective, relatively safe treatments, but unnecessary medication exposure should be avoided whenever a non-drug option will work.

Yaghi M, McMullan P, Rothe M, Grant-Kels J, Murase JE. Safety of dermatologic medications in pregnancy and lactation. October 2024, Journal of the American Academy of Dermatology CME.
Management guidelines for pregnant health care workers exposed to infectious dermatoses. International Journal of Women’s Dermatology.#10.1016/j.ijwd.2020.04.004