Pregnancy and dermatologic therapy
Dermatologists
should be familiar with medication safety in pregnancy to be able to
prescribe safely and confidently to pregnant women or women who may
become pregnant during the course of treatment for dermatologic
conditions. Topical medications should be considered first-line therapy
for pregnant women, but certain systemic medications are safe to use in
pregnancy and may be prescribed if necessary. Dermatologic surgery may
be performed during the second trimester of pregnancy with proper
positioning, but elective procedures should be delayed until the
postpartum period.
Drug classification for pregnancy
Birth
defects related to the use of diethylstilbestrol and thalidomide in the
mid-20th century led to the development of the Food and Drug
Administration (FDA) Pregnancy and Lactation Categories.
2 One of 5 categories is assigned to each drug before it is released.
3
Because of the impossibility of conducting controlled studies with
medication use in pregnant women, these categories reflect a
risk-benefit ratio based on animal studies or epidemiologic data.
4 The classifications are included in
Table I.
3
Table I. US Food and Drug Administration pregnancy risk categories
| Category | Description |
|---|
| X | Contraindicated in pregnancy; there is no reason to risk use of drug in pregnancy |
| D | Positive evidence of risk to human fetus, but benefits may outweigh risks of drug |
| C | Risk
cannot be ruled out; human studies have not been performed; animal
studies may or may not show risk; potential benefits may justify
potential risk |
| B | No risk to human fetus despite possible animal risk; or no risk in animal studies and human studies not done |
| A | Controlled studies show no fetal risk |
Although
the FDA pregnancy classifications are the most widely used, other
sources for determining the safety of a medication during pregnancy
include Teratogen Information Service, Reproductive Toxicology Service (
www.reprotox.org),
Drugs in Pregnancy and Lactation by Briggs et al,
5 US Pharmacopeial Dispensing Information,
6 and case reports.
3
Because the FDA can be slow to update the ratings based on the most
recent data and research, sources such as the Reproductive Toxicology
Service World Wide Web site may be more up to date.
1
Timeline for risk
When
prescribing a medication, it is important to determine whether a
patient is actively preventing pregnancy with contraception, trying to
conceive or not preventing pregnancy, or is currently pregnant in a
specific trimester and/or period of development (preimplantation,
embryonic, or fetal).
1
For sexually active women not on contraception, there is an 85% chance of becoming pregnant within 1 year.
7
Avoiding potentially teratogenic agents during the embryonic period,
which is the second through the eighth week after conception when
organogenesis occurs, is especially important.
1
Because some women will not have a positive home pregnancy test result
until up to 5 weeks after conception, these patients should be treated
with medications that are safe during pregnancy.
1
Although the highest period of risk is during organogenesis, certain
structures, such as the brain, teeth, and bones, remain susceptible
after 9 weeks. Thus, some medications that do not cause harm during
organogenesis may cause complications later in pregnancy.
1
Topical medications during pregnancy
For
most dermatologic conditions in pregnancy, topical treatments remain
the safest choice and should be considered first-line therapy.
Table II summarizes the pregnancy classifications and risks of each topical medication.
Table II. Pregnancy classifications and risks of topical medications for dermatologic therapy
| Medication | Pregnancy category | High-risk period | Risks/comments |
|---|
| Retinoids |
 Tretinoin | C | First trimester | Possible teratogen in first trimester, absorption minimal |
| Adapalene | C | First trimester | Possible teratogen in first trimester, absorption minimal |
| Tazarotene | X | Entire pregnancy | Retinoid-like anomalies in animal studies |
| Antibacterials |
| Clindamycin | B | None | |
| Erythromycin | B | None | |
| Metronidazole | B | None | |
| Dapsone | C | End of third trimester | Theoretical risk of neonatal hyperbilirubinemia if used near time of delivery |
| Mupirocin | B | None | No large studies available |
| Neomycin | B | None | No large studies available |
| Polymyxin B | B | None | No large studies available |
| Nonantibacterial antiacne products |
| Sodium sulfacetamide | C | None | |
| Benzoyl peroxide | C | None | |
| Salicylic acid | C | None | Do not apply over large areas under occlusive dressings, 9-25% absorbed |
| Azelaic acid | B | None | <4% Absorbed |
| Immunosuppressants |
| Corticosteroids | C | Third trimester with high doses | Possible risk of low birth weight in some studies with excessive absorption |
| Tacrolimus | C | None | Data in human beings limited |
| Pimecrolimus | C | None | Data in human beings limited |
| Antipsoriatics |
| Calcipotriene | C | None | Skeletal abnormalities in animal studies, no such findings in human studies |
| Anthralin | C | None | No evidence of systemic absorption, no studies during pregnancy in human beings or animals |
| Antifungals |
| Clotrimazole | B | None | |
| Oxiconazole | B | None | |
| Econazole | C | None | Limited data |
| Ketoconazole | C | None | Limited data |
| Ciclopirox | B | None | |
| Naftifine | B | None | |
| Terbinafine | B | None | |
| Butenafine | B | None | |
| Nystatin | B | None | |
| Antiparasitic |
| Permethrin | B | None | Has been used extensively in pregnancy |
Acne and rosacea
For
acne and rosacea, a plethora of topical medications are available, most
of which are safe for use during pregnancy. The topical retinoids
tretinoin and adapalene are category C. Some studies suggest that
topical tretinoin is teratogenic in the first trimester,
8,
9,
10 but another study contradicts that finding.
11
Absorption is minimal, and risk is unlikely, but alternative treatments
should be considered in the first trimester if they are available.
12
Adapalene, also category C, has minimal absorption, so use during
pregnancy could be considered once the benefits and risks have been
discussed with the patient.
12
Data suggest that the potential risk of teratogenicity of both agents
is only during the first trimester, and no problems have been reported
in studies where use occurs in the second and third trimester.
12
A practical approach would be to consider treatment with these agents
after the first trimester in consultation with the patient’s
obstetrician. Topical tazarotene, on the other hand, is category X
because of retinoid-like anomalies found in animal studies, so it is
contraindicated.
12
Antibacterial
topical agents used for acne and rosacea include clindamycin,
erythromycin, and metronidazole, all of which are category B and safe
throughout pregnancy.
12
Topical dapsone, a category C medication, has been used safely as an
oral medication in pregnancy for both leprosy and dermatitis
herpetiformis, and no fetal risks are reported in the literature.
12
There is a theoretical risk of neonatal hyperbilirubinemia when used
near the time of delivery, so the prescribing physician should consider
stopping treatment before the last month of pregnancy.
12
Topical sodium sulfacetamide, on the other hand, is a category C
medication that is not associated with hyperbilirubinemia, so its use is
not contraindicated anytime during pregnancy.
12
The nonantibacterial antiacne product benzoyl peroxide is category C
because human studies have not been conducted, but it is considered safe
to use during pregnancy and is a treatment of choice for acne in
pregnant patients.
1,
4,
12
Salicylic acid, another nonantibacterial antiacne product, is also
category C. Although this is an nonsteroidal anti-inflammatory drug,
which is generally contraindicated in pregnancy because of the potential
for oligohydramnios and early closure of the ductus arteriosus in the
third trimester,
1 the systemic absorption is estimated to be between 9% and 25%.
13,
14,
15 Because of its minimal absorption, there is a very low teratogenic potential,
16
and pregnant women should simply be advised not to apply topical
salicylic acid for prolonged periods over large areas or under occlusive
dressings, which would enhance systemic absorption. Azelaic acid is
pregnancy category B because animal studies show no adverse effects, and
less than 4% of the applied dose is systemically absorbed.
4,
12,
15
Psoriasis and atopic dermatitis
For
inflammatory skin conditions such as psoriasis, topical corticosteroids
are considered first-line therapy in pregnant patients. A detailed
review of pregnancy and psoriasis was performed by Tauscher et al
17
in which they outlined a stepwise approach for treatment. For localized
disease in pregnancy, they recommended topical corticosteroids as
first-line therapy followed by stepwise therapy with topical
calcipotriene, anthralin, and tacrolimus.
1
Although all of these topical medications are category C, there are
many data on corticosteroid use for a variety of medical conditions in
pregnancy, so they are currently the preferred first-line therapy.
The
absorption, and therefore the safety in pregnancy, of topical
corticosteroids is related to a number of factors, including the vehicle
of administration, amount applied, occlusion, and sites of application.
4
A practical approach to therapy with topical corticosteroids in
pregnant women would be to advise them not to apply large amounts over
extensive areas or under occlusive dressings to avoid excessive
absorption
16 because of certain studies that associate such use with a risk of low birth weight.
12
In
pregnancy, topical calcipotriene should be considered the next step in
therapy for psoriasis. Topical calcipotriene is FDA pregnancy category
C, and although skeletal abnormalities have occurred in animal studies,
no such findings have been shown in human beings.
12
Practical usage limits and avoidance of occlusive dressings as
described above for topical steroids will likewise help avoid systemic
absorption and lower the risk of vitamin D toxicity. If both topical
steroids and calcipotriene fail, alternative options for topical
treatment are anthralin and tacrolimus.
1
There are no studies on the use of anthralin during pregnancy in human
beings or animals, but because there is also no evidence of systemic
absorption after topical application, its use is not contraindicated.
16
Likewise, data in human beings are limited for tacrolimus, but there
have been no problems reported from topical use during pregnancy.
12,
16
Both anthralin and tacrolimus are pregnancy category C, and until more
data are available on their use in pregnancy, they remain third- and
fourth-line treatment options.
Pimecrolimus is a common topical
treatment for atopic dermatitis. Similar to tacrolimus, it is a category
C medication and no problems have been reported from its use during
pregnancy, but data are limited.
12 If topical corticosteroids fail, pimecrolimus would be an acceptable topical treatment for atopic dermatitis during pregnancy.
Topical antimicrobials
For
bacterial infections, topical antibiotics such as mupirocin, neomycin,
and polymyxin B are not associated with teratogenicity.
12 Large studies have not been conducted on any of these, but they are considered safe to use during pregnancy.
12
Topical
antifungals are considered a safer alternative to oral antifungals
during pregnancy. Of the imidazoles, the 2 preferable options are
clotrimazole and oxiconazole, which are both category B.
4
All other topical imidazoles, including econazole and ketoconazole, are
category C because of limited data, but no specific adverse effects
from the use of these topical imidazoles have been reported.
12
Topical ciclopirox, naftifine, terbinafine, butenafine, and nystatin
are all category B because there have been no problems reported from
topical use during pregnancy.
12
Topical
permethrin is the drug of choice for scabies and lice occurring in
pregnancy and is poorly absorbed. It has been used extensively with
minimal adverse effects reported, thus it is category B.
12
Systemic medications during pregnancy
Although
systemic medications should only be used when absolutely necessary
during pregnancy, it is important to know the safety ratings of systemic
treatments for common dermatologic conditions, especially for patients
who may become pregnant during the course of treatment or in
circumstances where delaying or interrupting treatment until pregnancy
is completed is not advisable.
Table III summarizes the pregnancy classifications and risks of each systemic medication.
Table III. Pregnancy classifications and risks of systemic medications for dermatologic therapy
| Medication | Pregnancy category | High-risk period | Risks/comments |
|---|
| Antibiotics |
| Tetracyclines | D | Second and third trimester | Dental staining and enamel hypoplasia in second and third trimester, has been associated with acute fatty liver of pregnancy |
| Erythromycin | B | First trimester | Hepatotoxicity rare with prolonged use in pregnancy, possible increased risk of cardiovascular malformations in early pregnancy |
| Azithromycin | B | None | |
| Penicillins | B | None | |
| Cephalosporins | B | None | |
| Retinoids |
| Isotretinoin | X | Entire pregnancy | Increased
fetal loss in first trimester, microtia, external ear canal stenosis,
cleft palate, hydrocephalus, cardiac outflow tract defects |
| Acitretin | X | Entire pregnancy | Craniofacial, cardiac, thymic, and central nervous system malformations |
| Diuretic/antiandrogenic |
| Spironolactone | C | After 8 wk | Delayed
sexual maturation of female rat fetuses and feminization of male rat
fetuses in animal studies; risk to human fetus is only theoretical, as
case reports show no adverse effects in human pregnancy |
| Antirheumatics/antimetabolites |
| Methotrexate | X | Entire pregnancy | Increased
risk of miscarriage, micrognathia, developmental delays,
craniosynostosis, small low-set ears, limb abnormalities, and growth
retardation |
| Hydroxychloroquine | C | None | Not associated with a specific congenital malformation |
| Immunosuppressants |
| Cyclosporine | C | None | No specific birth defects, data on long-term outcomes lacking |
| Corticosteroids | C | Third trimester with high doses | Potential for growth retardation and inhibition of endogenous corticosteroid production when used in high doses |
| Mycophenolate mofetil | D | Entire pregnancy | Increased risk of miscarriage and anomalies of distal limbs, heart, esophagus, kidney, external ear, and face |
| Phototherapy |
| Broadband ultraviolet B phototherapy | - | First 28 d of pregnancy | Avoid overheating during therapy |
| Biologics |
| Adalimumab | B | None | Limited data |
| Etanercept | B | None | Limited data |
| Infliximab | B | None | Limited data |
| Antihistamines |
| Cetirizine | B | None | Potential sedation of neonate in nursing mothers |
| Diphenhydramine | B | None | Potential sedation of neonate in nursing mothers |
| Loratadine | B | None | Potential sedation of neonate in nursing mothers |
| Chlorpheniramine | B | None | Potential sedation of neonate in nursing mothers |
| Antifungals |
| Terbinafine | B | None | Do not electively use to treat onychomycosis during pregnancy per manufacturer |
| Griseofulvin | C | Entire pregnancy | Increased risk of skeletal and central nervous system anomalies and fetal loss |
| Ketoconazole | C | Entire pregnancy | Sexual ambiguity of a male fetus, can interfere with pregnancy implantation |
| Itraconazole | C | None | Lowest teratogenic potential of all imidazoles |
| Fluconazole | C | None | Single-dose use confirmed safe |
| Antiparasitic |
| Ivermectin | C | None | Teratogenic to animals in high doses |
Acne
Acne is a common condition that is generally unaffected by pregnancy.
1
The 2 most common systemic medications used to treat acne are
antibiotics and isotretinoin. Isotretinoin is category X and should be
avoided during pregnancy or in those patients trying to conceive.
18
Increased fetal loss may result from first-trimester use, and specific
malformations including microtia, stenosis of the external ear canal,
cleft palate, hydrocephalus, and cardiac outflow tract defects may occur
with use later in pregnancy.
1
The risks of systemic retinoid exposure during embryogenesis have been
extensively reviewed, and a detailed discussion is beyond the scope of
this review article. We would direct interested readers to the included
references.
19,
20,
21,
22,
23,
24,
25,
26,
27,
28
Tetracyclines
are known to deposit in developing bones and teeth during the second
and third trimester, resulting in enamel hypoplasia and a yellowish
staining of the teeth that will darken over time.
12,
29
Tetracyclines have also been associated with acute fatty liver of
pregnancy, which is a potentially fatal syndrome that occurs in the
third trimester.
4 Interestingly, tetracyclines have not been associated with congenital anomalies during the first trimester,
12
so as long as they are discontinued as soon as pregnancy is suspected,
there is very little risk. However, because of multiple concerns with
use during the second and third trimester, they are classified as
category D and should be avoided during later pregnancy. Erythromycin is
category B and is considered safe in pregnancy; however, hepatotoxicity
may rarely occur with prolonged use of the erythromycin ethylsuccinate
formulation in pregnant patients.
4
In addition, 2 Swedish studies have reported an increased risk of
cardiovascular malformations when erythromycin was used early in
pregnancy.
30,
31
Alternative antibiotics in later pregnancy are azithromycin,
penicillins, and cephalosporins, all of which are pregnancy category B.
5
Spironolactone,
an antiandrogenic drug that competitively inhibits 5α-reductase and
aldosterone, is often prescribed off-label for acne.
32
Pregnancy category C, spironolactone caused feminization of male rat
fetuses and delayed sexual maturation of female rat fetuses in animal
studies, but those effects have not been observed in human beings.
1
The differentiation of the urogenital tract does not occur until after 8
weeks, so any theoretical risk would occur after that point,
1
but 2 case reports of 5 pregnancies where spironolactone was used by
the mother showed no abnormalities in the 2 female and 3 male children.
33,
34
Psoriasis
Psoriasis, a chronic inflammatory skin condition, affects 2% to 3% of the population,
35,
36 and data show that 44% of patients with psoriasis were female and of reproductive age.
17
It is expected, then, that all dermatologists will encounter pregnant
patients and patients of childbearing age with psoriasis. Approximately
50% of women with psoriasis will improve during pregnancy, but it can
worsen in up to 20%.
1
Topical treatments are first-line therapy for psoriasis, but systemic
treatments may be required for moderate to severe disease.
Oral
retinoids, such as acitretin, that are used to treat psoriasis cause
craniofacial, cardiac, thymic, and central nervous system malformations
and are contraindicated in pregnancy.
16 Like all oral retinoids, acitretin is a category X medication.
Methotrexate,
a folic acid antagonist used to treat inflammatory skin disorders such
as psoriasis, is also used as an abortifacient for conditions such as
ectopic pregnancy, so it is contraindicated in pregnancy. Aside from an
increased risk of miscarriage, associated malformations include
micrognathia, developmental delays, craniosynostosis, small low-set
ears, limb abnormalities, and prenatal growth retardation.
37,
38
Cyclosporine,
a category C medication used for moderate to severe psoriasis, acts as a
selective immunosuppressant by inhibiting T lymphocytes.
16
It has mainly been studied in pregnant organ transplant recipients,
making it difficult to separate the effects of cyclosporine from those
of other medications.
16 No specific birth defect has been attributed to cyclosporine, but data on long-term outcomes are lacking.
4 For pregnant patients, its benefits outweigh any theoretical risks, and it appears to be safe for the fetus.
1
Broadband ultraviolet B phototherapy is considered safe during pregnancy, with no adverse outcomes reported in studies.
39,
40
For extensive psoriasis during pregnancy, this appears to be the safest
systemic therapy, but overheating during treatment should be avoided
because of an increased risk of neural tube defects if hyperthermia
occurs during neural tube formation in the first 28 days of gestation.
1,
2
Data
are currently limited on biologic agents such as adalimumab,
etanercept, and infliximab, but all are listed as pregnancy category B.
Pregnancy registries have been established for these medications, but
given the limited data, the benefits of therapy should be carefully
weighed against any unknown risk to the fetus.
12
Currently, no specific congenital malformations have been attributed to
any of the above medications when used at any time during the
pregnancy.
Atopic dermatitis
For
atopic dermatitis during pregnancy, topical medications should be
prescribed initially, but the occasional use of systemic steroids may be
considered in severe or refractory cases. Pregnancy category C, oral
steroids appear to be safe when used in moderate doses and for the
shortest duration possible.
5
Some potential problems with high doses of systemic corticosteroid use
during pregnancy include intrauterine growth retardation and inhibition
of endogenous corticosteroid production.
6,
41,
42,
43,
44
Some studies have shown an association between orofacial clefts and
corticosteroid use in pregnancy, but a recent publication by Hviid and
Molgaard-Nielsoen
45
shows no such association. When faced with a patient with a severe
atopic dermatitis flare, either systemic corticosteroids or cyclosporine
would be acceptable choices, as neither is associated with an increase
in congenital malformations when used in pregnancy for other conditions
such as asthma and autoimmune disease.
1
Mycophenolate
mofetil, an immunosuppressive agent used to treat moderate to severe
refractory atopic dermatitis, has been assigned a pregnancy category D
because of an increased rate of spontaneous abortions and certain
congenital malformations including anomalies of the distal limbs, heart,
esophagus, and kidney as well as external ear and facial abnormalities
such as cleft lip and palate.
16 Mycophenolate mofetil should be avoided during pregnancy and in women who are not actively preventing pregnancy.
For
conditions such as atopic dermatitis, antihistamines may be used for
itching. Most antihistamines, including cetirizine, diphenhydramine,
loratadine, and chlorpheniramine are pregnancy category B and are safe
to use.
12
It is important to note that antihistamines should be avoided during
lactation in nursing mothers if possible because of possible sedating
effects on the neonate.
12
Connective tissue disease
For
pregnant women with severe discoid lupus or systemic lupus
erythematous, the systemic medication hydroxychloroquine is category C
and has not been associated with a specific congenital malformation.
Because stopping hydroxychloroquine can precipitate a lupus flare, most
experts recommend continuing therapy if it is currently in use when a
patient becomes pregnant.
1
When faced with a patient with cutaneous lupus who is not at risk for a
systemic flare and who is either pregnant or trying for pregnancy,
short-term oral steroids along with topical steroids may be a better
treatment option because more data are available regarding
corticosteroid use in pregnancy.
Fungal and parasitic infections
For fungal infections during pregnancy, oral antifungals pose greater risks than topical agents.
4
That said, terbinafine is a category B medication because of a low risk
for fetal harm in animal studies and is the systemic treatment of
choice for a dermatophyte infection during pregnancy. The manufacturer
does recommend not using oral terbinafine electively to treat
onychomycosis during pregnancy.
12
The
other major antifungals, griseofulvin and the imidazoles, are all
pregnancy category C. In animal studies, griseofulvin showed an
increased risk of skeletal and central nervous system anomalies and of
fetal loss.
1,
4 Certain studies indicate an increased risk for conjoined twins as well,
1,
12
so griseofulvin use during pregnancy is not recommended. Ketoconazole
can inhibit androgen synthesis, increasing the risk of sexual ambiguity
of a male fetus.
1 It can also impair progesterone secretion and interfere with early pregnancy and implantation,
4
so it should not be used during pregnancy. The newer imidazoles
itraconazole and fluconazole, both category C, have been the subject of
large cohort studies that indicate neither is teratogenic.
1
Some studies suggest that fluconazole should be avoided in prolonged
high doses to avoid the risk of malformations, but multiple studies have
confirmed the safety of a single oral dose, typically used by
obstetricians to treat vaginal candidiasis.
4,
12 Itraconazole has the lowest teratogenic potential because it has minimal effect on the steroid hormones.
12
Finally,
because it is teratogenic to animals in high doses, the category C
medication ivermectin should be avoided as a treatment for scabies in
lieu of permethrin, a safer topical FDA category B medication.
12
Dermatologic surgery during pregnancy
Most
experts agree that nonemergent surgery during pregnancy be performed
during the second trimester (weeks 13-24) or postpartum to avoid the
possible risk of spontaneous abortion in the first trimester or preterm
labor in the third trimester.
46
If possible, the patient should be placed in the left lateral position
to avoid compression of the vena cava by the pregnant uterus, but
positioning on the right side is an acceptable alternative to avoid
supine positioning.
46
Alcohol and chlorhexidine preparations for the surgical site are
acceptable to use during pregnancy, but povidone-iodine absorption
through mucous membranes has been associated with fetal hypothyroidism.
47,
48,
49 and hexachlorophene has been reported to cause fetal central nervous system toxicity.
47,
48
Most
dermatologic procedures can be performed using local anesthetics.
Lidocaine and prilocaine are both category B medications, and multiple
studies have shown no increased risk of adverse effects in the fetus.
46
Local anesthetics do cross the placental barrier, but the only
potential risk to the fetus would be in the case of injection of
excessive amounts or inadvertent arterial injection.
50 Risks to the fetus in that case would be central nervous system or cardiac toxicity.
46 Local anesthetics such as mepivacaine and bupivacaine increase the risk of fetal bradycardia,
51 so lidocaine and prilocaine would be the anesthetics of choice.
Epinephrine
is often added to lidocaine in small concentrations as a
vasoconstrictor to reduce bleeding at the operative site. It is a
category C medication because of decreased uterine blood flow with use
during animal experiments.
46
Considering the dilution and small amounts used during dermatologic
procedures, potential risk is probably outweighed by the benefits of
decreased bleeding during procedures, so epinephrine is considered safe
when used judiciously.
46
With
regard to antibiotics and pain control, medications that are category A
and B should be first-line. Antibiotics were previously discussed in
the section on systemic medications. For pain control, acetaminophen is
category B and is first-line. Opioid narcotic pain medications are all
category C because of the risk of neonatal respiratory depression from
high doses used near the time of delivery and the risk of neonatal
withdrawal from chronic maternal use.
12
If opioids are necessary for pain control, they should be used in the
lowest dose and for the shortest possible duration to avoid fetal
withdrawal.
1
Also, pain medications including nonsteroidal anti-inflammatory drugs
should be avoided because of the risk of oligohydramnios and premature
closure of the ductus arteriosis.
1
Procedures
such as cryotherapy, laser ablation, and application of trichloroacetic
acid that involve local destruction of lesions without anesthetics are
safe to perform during pregnancy.
1
Podofilox, 5-fluorouracil cream, and interferon are not recommended
during pregnancy, however, because of concerns regarding maternal and
fetal safety.
1
Summary
When
choosing treatments for dermatologic conditions during pregnancy, a
conservative approach is best. Topical medications are first-line
because they are minimally absorbed, but certain oral medications are
safe to use when topical therapy fails or is not possible. Elective
surgical procedures should be delayed until the postpartum period, but
when necessary, dermatologic surgery during the second trimester using
local anesthetics and proper patient positioning may be performed.
