Drugs for skin disorders in pregnancy: expert opinion.
The information available can be confusing, added Dr. Reed of the University of Colorado, Denver. There are two separate ratings that categorize drugs by their risk in pregnancy, for example--one by the Food and Drug Administration and the other in the standard textbook on the subject, "Drugs in Pregnancy and Lactation," by Gerald G. Briggs, B.Pharm., et al.
Dermatologists and obstetricians need to communicate with each other about treatment strategy, said Dr. Reed, who nated that she practiced office gynecology for a decade before training as a dermatologist.
"You want to have everybody on board," she said.
Dr. Reed then offered her picks for treatment of several skin problems in pregnancy.
* Acne. If you have to use a systemic therapy (most patients will refuse), erythromycin or amoxicillin may be your best bet. Both drugs are category B.
Topically, Dr. Reed uses erythromycin, benzoperoxide, azelaic acid, clindamycin, or metronidazole.
Although benzoperoxide products are FDA category C, they are widely available over the counter and there is nearly no evidence that they cause problems during pregnancy, she said.
Dr. Reed avoids topical retinoids throughout pregnancy, even though some sources list them as a safe choice, because of "political" reasons, she added. An attorney would have no problem finding reports of congenital anomalies associated with the mother's use of topical retinoids in the first trimester of pregnancy.
"You have other drugs you can use," or you can refer the patient to an aesthetician, she said.
* Fungus or yeast. Any topical therapy is fine; most are FDA category B.
Among oral therapies, nystatin appears to be safe (category B). She avoids fluconazole, itraconazole, and terbinafine, especially for problems that can be treated after pregnancy, such as a toenail fungus.
Even though these three drugs probably are low-risk, there have been some reports of minor malformations with prolonged use of fluconazole and itraconazole, and data are lacking for terbinafine.
For systemic infections, consult carefully with infectious disease specialists and other colleagues.
* Scabies. Dr. Reed would choose permethrin (category B). Lindane also is category B but historically has been avoided in pregnancy. A recent FDA warning said to limit use of lindane shampoo in pregnancy to the second trimester.
Crotamiton and ivermectin are category C.
* Rashes. Oral glucocorticoids (category C) have not been adequately studied in humans but have been associated with infant hypoadrenalism and other risks.
"I'm extremely careful during the first trimester of pregnancy" and educate patients extensively about the potential risks before prescribing corticosteroids in pregnancy, she said.
Among antibiotics, Dr. Reed said she prefers penicillin or erythromycin (category B).
Avoid erythromycin in the perinatal period because it may cause pyloric stenosis, a recent report suggested. Ciprofloxacin in pregnant animals caused joint problems.
Data are limited for topical immunomodulators during pregnancy. Pimecrolimus and tacrolimus are category C.
Information on Drug Risk in Pregnancy
* Organization of Teratology and Information Services: www.otispregnancy.org. Find a phone number for the Teratogen Information Service nearest you through this site by using the map at http://otispregnancy.org/ otis_find_a_tis.htm.
* Motherisk: www.motherisk.org. The Canadian site for safety issues during pregnancy.
* European Network of Teratology Information Services: www.entisorg.com.
* www.perinatology.com: Includes information about drugs used around the time of delivery.
* Toxnet: http://toxnet.nlm.nih.gov. For general toxicology information. Run by the National Library of Medicine.
* "Drugs in Pregnancy and Lactation," by Gerald G. Briggs, B.Pharm., et al. Available in most university hospital libraries and reference sections.
* "Medications and Mother's Milk: A Manual of Lactational Pharmacology," by Thomas W. Hale, Ph.D.
* "Physicians' Desk Reference," by Thomson PDR. Includes the Food and Drug Administration's use-in-pregnancy ratings for drugs and a list of Drug Information Centers.
* Teratogen Information System (TERIS): http://depts.washington. edu/terisweb/teris. Run by the University of Washington.
* Reprotox: www.reprotox.org.
Source: Dr. Barbara R. Reed.
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|Publication:||OB GYN News|
|Date:||Sep 15, 2003|
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