Pregnancy acne: causes, timing and safe care

Acne during pregnancy is common, and it can show up in people who never had acne before. It is mostly driven by the hormone changes of pregnancy. The hard part is treatment, because several of the strongest acne medicines can harm a developing baby and must stop. This guide covers why pregnancy acne happens, when it tends to be worst, which acne medicines to stop, and what the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Dermatology (AAD) say about care. For the wider plan outside pregnancy, see the hormonal acne treatment guide.

Skinli gives general education and is not a doctor. In pregnancy, check every acne product and medicine with your obstetrician, midwife or dermatologist before using it.

If you are planning a pregnancy

Acne care should change before pregnancy starts. The 2022 review says isotretinoin and spironolactone need to be stopped for at least 1 month before trying to get pregnant. The UK's NICE guideline tells doctors to explain that retinoid creams and gels and tetracycline antibiotics must not be used during pregnancy or while planning one. The AAD's advice for adults is to see a dermatologist before treating acne on your own if you are pregnant or trying to get pregnant, because some store-bought acne treatments are not safe in pregnancy.

How common it is

ACOG says many women have acne during pregnancy. Some already have acne and notice it get worse. Others who always had clear skin develop acne while pregnant. A 2022 review in Dermatology and Therapy says survey studies have found acne in up to 43% of people during pregnancy, and adds that data are limited.

What causes it

NIAMS, part of the US National Institutes of Health, says hormonal changes related to pregnancy can cause acne. The NHS and the AAD both list pregnancy among the hormone changes that lead to breakouts. ACOG says some skin changes in pregnancy come from hormone changes, while for most of them doctors are not sure of the exact cause.

A 2020 study of 295 pregnant women with acne in Turkey concluded that pregnancy acne shares many features with adult female acne, and that changes in many hormones play a complex part that is not yet understood.

When it is worst, and who gets it worst

The 2022 review says acne in pregnancy is usually inflamed, spreads to the trunk, and is most severe in the second and third trimesters. The 2020 study found that acne on the chest and back, the severity of facial acne and extra hair growth were all higher in the third trimester than earlier.

The 2020 study concluded that severe acne is generally uncommon in pregnancy. In that study, 56.6% of the women had mild acne, 29.5% moderate acne, and 1.7% had the highest grade on the study's scale. Women were more likely to have severe acne if they had:

• Irregular periods before pregnancy
• PCOS, now also called PMOS (see PCOS acne)
• Extra hair growth
• A higher body weight

The 2022 review adds age 25 or younger and a first pregnancy as possible risk factors, and says these links are not well established. It also lists a female baby among them. Because the review calls these links not well established, acne cannot predict the baby's sex.

Is acne a sign of pregnancy?

Acne alone cannot answer this. Acne flares with periods too: a 2001 study found that 44% of women had flares before their periods. If your period is late, take a pregnancy test. If you might be pregnant, stop and check before using any of the medicines in the next section.

Acne medicines to stop in pregnancy

The AAD says to stop these immediately if you are pregnant, because they can cause serious birth defects:

Medicine	What the sources say
Isotretinoin	Causes severe birth defects. See Accutane and pregnancy
Tazarotene	A prescription retinoid for the skin. The AAD lists it with isotretinoin
Spironolactone	The FDA label says animal studies showed feminization of male fetuses. See spironolactone for acne

Other medicines need a change or a talk with your doctor:

• Adapalene and tretinoin. The AAD says most experts recommend stopping them in pregnancy. NICE, the UK guideline body, says topical retinoids should not be used in pregnancy or while planning one. See retinoids during pregnancy and breastfeeding.
• Tetracycline antibiotics. The AAD says to stop doxycycline, minocycline or tetracycline by the 15th week. ACOG says they can discolor the baby's teeth if taken after the fourth month.
• Hormone-blocking medicines. ACOG says medicines that block hormones to treat acne are not recommended in pregnancy because of the risk of birth defects.

What you can use

ACOG says these ingredients in store-bought products can be used during pregnancy:

• Benzoyl peroxide on the skin
• Azelaic acid
• Salicylic acid on the skin
• Glycolic acid

It says to ask your obstetrician before using any product with an ingredient not on this list. The AAD is more cautious about two of them. It says benzoyl peroxide is considered safe in limited amounts, and salicylic acid is generally considered safe when used for a limited time, and that you should talk with your obstetrician or dermatologist before using either. The 2022 review says pregnant patients should avoid putting salicylic acid over large areas for long periods.

The ingredient guides go into detail: salicylic acid during pregnancy, azelaic acid during pregnancy and niacinamide during pregnancy.

Gentle skin care

ACOG's steps for acne in pregnancy:

1. Wash your face twice a day with a mild cleanser and lukewarm water.
2. If your hair is oily, shampoo every day and keep your hair off your face.
3. Do not pick or squeeze spots, to lower the risk of scars.
4. Choose oil-free cosmetics.

Supplements and herbs

The US National Center for Complementary and Integrative Health says many dietary supplements have not been tested in pregnant women. Some supplements sold for acne contain high doses of vitamin A, which can cause birth defects. The supplements guide lists what to avoid.

When acne is severe

If acne is deep, painful or scarring during pregnancy, see a dermatologist. The 2022 review describes a stepwise approach: treatments on the skin for mild to moderate acne, adding certain antibiotic pills that are considered safer in pregnancy for moderate to severe acne, and other options for the most severe cases. The AAD says lasers have been used safely in pregnant women for medical conditions, but some need a numbing medicine, so see a dermatologist first.

Dark patches and other skin changes

ACOG lists several other skin changes that are common in pregnancy, including melasma, which is brown patches on the cheeks, nose and forehead, a dark line down the belly, stretch marks and small red spider veins. It says dark patches come from more melanin, the natural substance that gives skin its color, and that sunscreen and a wide-brimmed hat every day outside help keep melasma from getting worse. Dark patches usually fade after birth, though some last for years. See melasma.

Acne itself can leave dark marks, and the AAD says these can last for months. Azelaic acid, one of the ingredients ACOG lists for pregnancy, also fades the dark spots acne leaves behind, according to the AAD. Sunscreen helps both problems.

Questions to ask at your prenatal visit

• Which of my current acne products and medicines should I stop now?
• Can I use benzoyl peroxide, azelaic acid or salicylic acid, and on how much of my skin?
• Is my acne severe enough for a dermatologist?
• Which supplements or vitamins should I avoid?
• When can I restart my usual acne treatment after the birth, and does breastfeeding change that?

After the baby is born

The 2022 review says no acne treatment is strictly ruled out while breastfeeding, and that some treatments avoided in pregnancy, such as retinoid creams, become acceptable. It advises avoiding isotretinoin and dapsone gel while breastfeeding, and keeping creams off the breast area where the baby feeds. If you plan to restart spironolactone or birth control pills after the birth, ask your doctor when and which ones fit with breastfeeding.

Skinli's free acne plan uses adapalene, which the AAD says most experts recommend stopping in pregnancy. If you are pregnant, bring the plan to your obstetrician and ask which steps to swap.