Acne in Pregnancy

Why it flares, and why it can appear from nowhere

ACOG puts the two patterns side by side: "Many women have acne during pregnancy. Some already have acne and notice that it gets worse during pregnancy. Other women who may always have had clear skin may develop acne while they are pregnant."

That second sentence is the one people need. Pregnancy acne is not a sign that you have been doing something differently. It is one of a cluster of skin changes ACOG groups together: dark spots on the breasts, nipples or inner thighs, melasma, linea nigra, stretch marks, acne, spider veins, varicose veins, and changes in nail and hair growth.

On the cause, ACOG is refreshingly honest rather than confident: "Some are due to changes in hormone levels that happen during pregnancy. But for most skin changes health care professionals are not sure of the exact cause." Anyone offering you a single-hormone explanation is going beyond what the evidence supports.

The NHS describes the parallel pigment changes in plainer terms — nipples and the area around them going darker, skin colour darkening in patches or all over, and moles, freckles and birthmarks darkening — and notes these gradually fade after the birth.

The skincare routine ACOG recommends

Its list is short and deliberately unexciting:

• Wash your face twice a day with a mild cleanser and lukewarm water.
• If you have oily hair, shampoo every day and try to keep your hair off your face.
• Avoid picking or squeezing spots, to lessen possible scarring.
• Choose oil-free cosmetics.

Washing more aggressively, or scrubbing, is not on the list and tends to make things worse by stripping the skin barrier.

Over-the-counter ingredients ACOG says can be used

This is the section worth reading carefully, because it is one of the few places a national body publishes an explicit list rather than a vague reassurance. ACOG says over-the-counter products containing the following can be used during pregnancy:

• topical benzoyl peroxide
• azelaic acid
• topical salicylic acid
• glycolic acid

It adds the boundary: "If you want to use an OTC product that contains an ingredient not on this list, contact your obstetrician-gynecologist."

Note that this is a list of ingredients, not of brands or strengths. Read the ingredients panel rather than the marketing on the front, and ask your midwife or pharmacist if a product contains something you cannot place.

Prescription treatments to stop or avoid

ACOG names four categories that should not be used while you are pregnant, and gives its reasons:

• Isotretinoin. A form of vitamin A. ACOG states it "may cause severe birth defects in fetuses, including intellectual disabilities, life-threatening heart and brain defects, and other physical deformities."
• Oral tetracyclines. This antibiotic family "can cause discoloration of the fetus's teeth if it is taken after the fourth month of pregnancy and can affect the growth of the fetus's bones as long as the medication is taken."
• Hormonal therapy. Medicines that block specific hormones to treat acne are "not recommended due to the risk of birth defects."
• Topical retinoids. ACOG notes the amount absorbed is low, but says "it is generally recommended that use of these medications be avoided during pregnancy", and warns that retinoids appear in some over-the-counter products as well as prescriptions. Read labels.

If you are already using any of these, the right move is to speak to your GP, dermatologist or midwife rather than to panic. ACOG's framing is collaborative: "If you are concerned about which products to use to treat your acne, talk with your dermatologist and ob-gyn. Together you can decide which option is best for you."

What to expect over the pregnancy

There is no published timetable for pregnancy acne, and it is not predictable from one pregnancy to the next. What can be said from the guidance is that these are hormone-driven skin changes and that the pigment-related ones generally fade after birth. Acne behaves similarly for many people, though not universally.

What will not help is switching products every fortnight. Skin treatments of any kind take weeks to show an effect, and the constant changing is itself irritating.

The related changes that arrive at the same time

• Spider veins. ACOG attributes these to hormonal changes and the higher volume of blood in the body, says they are most common during the first half of pregnancy, and that "the redness should fade after the baby is born."
• Melasma. Brown patches on the cheeks, nose and forehead. ACOG's prevention advice is sunscreen and a wide-brimmed hat every day outdoors, because "the sun's UV rays can reach you even on cloudy days." It notes melasma usually fades after birth but can last years in some people.
• Sun sensitivity. The NHS warns you may burn more easily in pregnancy and advises a high-factor sunscreen and limiting time in the sun.

When to raise it

Acne is not a reason for an urgent call. It is worth raising at a routine antenatal appointment if it is severe, if it is affecting how you feel about yourself, or if you were on a prescription acne treatment when you found out you were pregnant. The last of those should be raised as soon as possible rather than at the next appointment.

And an itchy rash is a different symptom from acne. Itching in pregnancy, particularly without a rash and particularly on the palms and soles, has its own urgent pathway and should not be filed under skin changes.