Pregnancy-related skin conditions respond to combination approach

Key Points

Wailea, Hawaii - In the absence of incontrovertible data regarding best treatments for many skin issues associated with pregnancy, therapy often involves combination treatments, an expert says.

Physiologic skin changes associated with pregnancy include pigmentation changes, vascular ectasia and striae distensae, along with the appearance of "glowing" skin and faster-growing hair (often followed by hair loss) and nails, says Theodore Rosen, M.D., professor, department of dermatology, Baylor College of Medicine, Houston. Dr. Rosen spoke about this issue at MauiDerm 2010: Advances in Cosmetic and Medical Dermatology in January.

Melasma woes

Dr. Rosen says he prefers to use Tri-Luma (fluocinolone acetonide, hydroquinone, tretinoin; Galderma). However, "We must be circumspect about its use because of the potency of the steroid," he adds.

Other useful agents include Solagé (mequinol, tretinoin; Stiefel) and Glyquin (hydroquinone, glycolic acid; Valeant). "There's no substitute for broad-spectrum sunscreen for protecting against additional sun damage. I prefer Anthelios (La Roche-Posay)," Dr. Rosen says.

Struggling with striae

Striae impact an estimated 50 percent to 90 percent of pregnant women, Dr. Rosen says. "It appears that people who have stretch marks during their growth phase, and those whose mothers have stretch marks, face the highest risk (Chang AL, Agredano YZ, Kimball AB. J Am Acad Dermatol. 2004 Dec;51(6):881-885)." To prevent striae, "Some experts believe that regular moisturization - with shea butter, cocoa butter or gotu kola - is important," and that low-concentration alpha hydroxy acids (AHAs) are helpful, he adds.

"Combining moisturizers and AHAs seems to provide some protection for patients prone to developing stretch marks," he says, although randomized, controlled trials have shown no benefit for either of these approaches (Osman H, Usta IM, Rubeiz N, et al. BJOG. 2008 Aug;115(9):1138-1142).

Several recent reports tout fractional laser resurfacing (Fraxel, Solta Medical), even for tough-to-treat white stretch marks and skin of color (Katz TM, Goldberg LH, Friedman PM. Dermatol Surg. 2009 Sep;35(9):1430-1433. Epub 2009 Jun 22), although such treatments are costly, Dr. Rosen says.

Genital warts, HSV

For external genital warts, Dr. Rosen says imiquimod shows higher cure rates in nongravid women than in men. Based on a few small series, he says, "Imiquimod appears safe in pregnancy. The highest cure rate for the drug as approved, three times a week for up to 16 weeks, is just under 80 percent (Audisio T, Roca FC, Piatti C. Int J Gynaecol Obstet. 2008 Mar;100(3):275-276. Epub 2007 Nov 26)."

He adds that reducing the amount of affected tissue with CO₂ laser and then treating the remaining field or residual tissue with imiquimod is an effective combination in nongravid women. But in pregnancy, he adds, "We have no data to totally verify the effectiveness of this combination."

As for herpes simplex virus (HSV) in pregnancy, "The closer to the pregnancy the disease state was acquired, the higher the risk to the neonate, because less immunity can be transplacentally passed," Dr. Rosen says.

However, he adds that in a meta-analysis of six randomized, controlled trials, researchers concluded that the impact on the neonate of antiviral prophylaxis (with acyclovir or valacyclovir) in the third trimester could not be estimated. Nevertheless, Dr. Rosen recommends this approach partly because it is associated with a lower likelihood of cesarean section and positive culture at delivery (Hollier LM, Wendel DG. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004946).