Skin Care Ingredients and Supplements Pregnant or Nursing Women Should Not Use
Recently, I received an e-mail from a reader asking me if a skin care product was safe for her to use while she was pregnant or nursing. First and foremost, I am not a physician yet; therefore, you should speak to your primary care physician, obstetrician-gynecologist and/or dermatologist with regards to these types of questions. However, I was a bit alarmed by the dearth of information available to pregnant and nursing women online with regards to their skin care products and supplements. After doing some research, I decided to write an article supplying this type of information. I found that one or more licensed dermatologists and experts have recommended that women stop using or doing the following while pregnant or nursing:
Accutane (orally administered)
Accutane (isotretinoin) is a derivative of vitamin A commonly prescribed to patients with acne. According to the Organization of Teratology Information Services (OTIS), women who take Accutane during the first twelve weeks of pregnancy risk severe birth defects. These include severe fetal brain and heart defects, mental retardation, and other birth abnormalities. The correlation is strong, with one in four babies exposed to Accutane drug during the first trimester of pregnancy experiencing severe side effects. Fortunately, according to a 1995 survey in the New England Journal of Medicine, 99 percent of 177,216 women prescribed Accutane recalled being instructed to avoid pregnancy. Women who are taking Accutane and plan to become pregnant are advised by OTIS to stop using the product one month before trying to get pregnant, to be absolutely sure that the product is gone from the bloodstream.
Retin-A, Avita, Renova (topical treatments)
Retin-A, Avita, and Renova all contain tretinoin, like Accutane. All are topical treatments that are commonly prescribed to improve acne, hyperpigmentation, wrinkles, and skin texture. Each contains between 0.025-0.1% tretinoin and is applied to the skin, whereas Accutane is 10-40 mg of orally administered isotretinoin (USPharmacist.com). A 2002 study by Briggs et. al. cited here estimated that even if maximal absorption (about 33%) occurred from a daily application of 1 g of a 1% tretinoin preparation, a patient would receive only one-seventh of the vitamin A activity from a typical prenatal vitamin supplement. A further study by Lancet et. al. in 1993 affirmed this opinion, concluding that “topical tretinoin is not associated with an increased risk for major congenital disorders.” Still, despite the research otherwise, the Organization of Teratology Information Services (OTIS) says that is “a safe approach” for women to stop using Retin-A one month before trying to get pregnant.
…What about retinoids (retinol, retinyl palmitate) in over-the-counter topical treatments?
A 1999 review by G. Reis and R. Hess concluded that the form of retinoids commonly used in cosmetic products should be safe for use during pregnancy and while nursing. This is due in part because of the topical, rather than oral, administration of the drug. Another reason is that retinol and retinyl palmitate have about one-twentieth the potency of tretinoin (Lupo). This is because retinol and retinyl palmitate must first be converted to retinaldehyde, and then all-trans retinoic acid, in order to be effective. Therefore, based on the literature, it seems that topical treatments with retinol and retinyl palmitate should be safe. However, if you feel safer and can do without your cosmetic products with retinol and retinyl palmitate for nine months, then please do so.
Skin Care Supplements Containing Vitamin A (orally administered)
Skin care supplements often contain vitamin A. According to The Teratology Society, the USRDA (U.S. recommended daily allowance) of 8,000 IU/day during pregnancy has been established by the U.S. Food and Drug Administration (FDA) as the standard. Dietary surveys in the U.S., however, have defined that the average unsupplemented adult diet contains 7,000–8,000 IU/day of vitamin A (Russell-Briefel et al., ‘85). Because a higher instance of birth defects have been found in babies whose mothers consumed more than 10000 IU/day of vitamin A, and at least seven case reports of adverse pregnancy outcome associated with a daily intake of vitamin A of 25,000 IU or more have been published (Rosa et al., ‘86), women should consider their total dietary intake of vitamin A before taking vitamin A supplements. One further caveat: do not over-limit vitamin A, as retinol deficiency during pregnancy has been associated with anemia and other health problems. Further, one 1999 study of about 300 women did not find a link between consumption of about 50000 IU/day vitamin A and birth defects, but the current scientific literature overall seems to recommend about 8,000 IU/day during pregnancy, and ideally no more than 10,000 IU/day. If you are confused about your vitamin A intake, write down the foods and supplements you consume during a typical week, and ask your doctor or nutritionist.
Too much sun avoidance
Vitamin D deficiencies in pregnant women have been associated with the development of multiple sclerosis in babies (Chaudhuri). In addition, prolonged exclusive breastfeeding without vitamin D supplementation is one of the most significant causes of the reemergence of rickets (NIH). A 2007 study from the University of Pittsburgh found that both black and white women in North America are “at high risk” for vitamin D insufficiencies, even when taking prenatal vitamins. Therefore, pregnant women should spend sunscreen-free time in the sun to acquire adequate levels of vitamin D. According to Dr. Michael Holick of Boston University, standing outside sunscreen-free between the hours of 10 A.M. and 4 P.M. for fifteen minutes a day three times a week lets the skin produce enough vitamin D for most of the year. (Expose your face, arms, hands, and back.) Since CNCA.com reports that pregnant women should get the same amount of vitamin D as non-pregnant women, 400 IU, spending fifteen minutes sunscreen-free three days a week should be enough. Interestingly, too much sun is unlikely to create an excess of vitamin D, but too much vitamin D via supplement can. Excessive vitamin D levels have been associated with nausea, vomiting, poor appetite, constipation, weakness, weight loss, and calcinosis, the deposition of calcium and phosphate in the body’s soft tissues such as the kidney. Therefore, when pregnant or nursing, try to spend more sunscreen-free time in the sun, and take a vitamin D supplement, but keep total vitamin D from food and supplements below 50 micrograms, or 2000 IU.
Sunscreens containing avobenzone or oxybenzone
Before I continue any farther, I want to state first that no studies have been shown that avobenzone or oxybenzone are very toxic. In fact, a 2005 study by Hayden et. al. demonstrated that the ingredients are not harmful when applied to the skin. However, avobenzone and oxybenzone (the latter present in 20-30% of sunscreens) have been demonstrated by Hayden et. al to be absorbed into the body and secreted into the urine of users. According to Dr. Leslie Baumann, director of Cosmetic Dermatology at the University of Miami, “Oxybenzone has low acute toxicity in animal studies, yet little is known about its chronic toxicity and disposition after its topical application in people. For this reason, sunscreens containing this agent are not recommended for use in children.” And, again, although maximal absorption of a topical ingredient from the skin is about 33%, it is probably a safe approach to use sunscreens without avobenzone or oxybenzone during pregnancy or while nursing. A safe alternative is a sunscreen containing zinc oxide with its photoreactivity minimized by surface coating with dimethicone or silicone, such as Blue Lizard Australian Sunscreen, SPF 30 ($12.99, Drugstore.com).
Salicyclic Acid
[Thanks to a reader, this was added November 12, 2007.] Salicyclic acid has been shown in high doses of the oral form to cause birth defects and various pregnancy complications. However, small amounts applied to the skin — such as a salicylic acid-containing toner used once or twice a day — are considered safe, says Sandra Marchese Johnson, a dermatologist with Johnson Dermatology in Fort Smith, Arkansas. But the concern is stronger about face and body peels, which contain higher concentrations of salicylic acid. “This kind of ’soaking’ in the ingredient is similar to taking one or more aspirin when pregnant,” she explains. According to BabyCenter.com, your best bet is to consult your dermatologist about any products you are using containing salicyclic acid, and to avoid ingesting any supplements containing salicyclic acid or BHA (beta hydroxy acid; salicyclic acid is a BHA).
Just for you: Avoid soy that is not “active soy”, or oil of bergamot
[Thanks to a reader, this was added November 12, 2007.] Many women experience a darkening of the skin during pregnancy (”the mask of pregnancy”) that is caused by overactive melanin production. According to BabyCenter.com, soy-containing products and oil of bergamot have estrogenic effects, which can make this form of melasma (darkening of the skin) worse. However, products by Johnson & Johnson brands (i.e., Neutrogena, Aveeno, amongst others) contain a form of soy known as “active soy,” in which the estrogenic compounds have been extracted, so these should not exacerbate melasma like other products.
In summary…
Based on the scientific research available, while pregnant or nursing, it is vital to alter your skin care regime so that it does not include Accutane, to avoid taking supplements containing salicyclic acid or BHA, and to get at least fifteen minutes of sunscreen-free sun exposure at peak times of the day (10 A.M.-4 P.M.) three times a week to get adequate vitamin D, or talk to your doctor about a proper supplement. You should also avoid using products containing oil of bergamot or soy (although “active soy” is safe) to avoid the development of dark patches on the skin.
To be on the safe side, stop use of Retin-A one month before trying to become pregnant, stop using peels and acne treatments containing salicyclic acid, and be cautious about vitamin A supplements while pregnant or nursing.
To be extremely cautious while pregnant or nursing, stop using skin care products containing retinol or retinyl palmitate and stop using sunscreens containing oxybenzone or avobenzone.
And, again, I cannot stress this enough: speak to your primary care physician, obstetrician-gynecologist and/or dermatologist about any concerns you may have. Also, if you have anything to add to this article, please feel free to contact me at futurederm [at] gmail.com.
Tretinoin, Retinol, and Retinyl Palmitate: The Key to Anti-Aging Success?
Photo: Tretinoin treatments, courtesy Drugs.com.
According to Dr. David E. Bank, director of the Center for Dermatology, Cosmetic & Laser Surgery, researchers discovered the anti-aging properties of Retin-A, a prescription topical treatment containing a derivative of vitamin A, in 1985, when it was first used as an acne treatment. Patients reported decrease in the appearance of wrinkles and smoother skin, in addition to a reduction in acne.
The active ingredient in Retin-A, tretinoin (brand name Renova), is the only chemical to date to receive FDA approval for anti-aging and anti-sun damage properties. According to research by Fisher et. al cited by Dr. Leslie Baumann in Cosmetic Dermatology, retinoids are effective in preventing and treating the collagen loss caused by photodamage. UV exposure decreases collagen types I and III with 24 hours, but treatment of the skin with all-trans retinoic acid prevents the loss of these types of collagen synthesis. In addition, Fisher et. al demonstrated that application of tretinoin inhibits the induction of matrix metalloproteinase genes (more here), which are in part responsiblefor collagen degradation.
Side effects of retinol include skin irritation, desquamation, and redness. In addition, use of vitamin A derivatives has been associated with birth defects, and so it is advisable for women who are pregnant, breast-feeding, or those who may become pregnant to avoid use of tretinoin, retinol, or retinyl palmitate. It is further notable that patients with sensitive skin should use lower concentrations of tretinoin (0.025% rather than 0.1%) or, alternatively, lower concentrations of different metabolites of vitamin A, namely retinol or retinyl palmitate. According to Dr. Baumann, retinol and retinyl palmitate should be present in concentrations of at least 0.04% to 0.07% and packaged properly (to avoid oxidation) in order to be effective, as they are in Neutrogena Healthy Skin with SPF 20 ($19.99, Drugstore.com) and Roc Retinol Actif-pur ($16.99, Drugstore.com).
So how are retinol and retinyl palmitate related to the proven-effective tretinoin? According to Dr. Baumann, retinol is classified as a cosmetic rather than a drug because it must first be converted to retinaldehyde, and then all-trans retinoic acid within the skin in order to be effective. In general, retinol is considered to be about 20 times less potent than retinoic acid, and thus higher concentrations of retinol need to be used to achieve similar efficacy to all-trans retinoic acid (i.e., 0.04% or 0.07% versus 0.025%). However, although retinol needs to be present in higher quantities than tretinoin in order to be effective, patients typically experience lower levels of irritation using retinol products. Similarly, retinyl palmitate is a combination of pure retinol and palmitic acid (a substance typically used in cosmetics as a cleansing agent), and so it too must be converted to retinaldehyde and then all-trans retinoic acid within the skin in order to be effective. However, when present in sufficiently high concentrations, retinyl palmitate displays results similar to that of retinol. One caveat: based on information from Dr. Baumann’s site, make-up products with retinol will expire approximately one month after opening, so use accordingly.
Tretinoin itself is available in five prescription formulas: Retin-A Micro (Johnson & Johnson), Renova (Johnson & Johnson), Avita, Differin (Galderma), and Tazorac (Allergan). According to Dr. Bank, Retin-A Micro uses microsphere technology to allow a more sustained release of tretinoin over time. Some patients may find Retin-A Micro drying, in which case Renova, a product with tretinoin delivered in a mineral-oil base, may be recommended. A third option, Avita, is considered to be less irritating than Retin-A Micro, but without the mineral-oil base that can stimulate acne in some patients. The fourth option, Differin, contains a different chemical, adapalene, and is considered to make skin less photo-sensitive than other tretinoin products. Lastly, the newest product, Tazorac, contains tazarotene, and may be drying, but was approved by the FDA in 1997 for the treatment of acne. According to Dr. Baumann, a 2000 study by Kakita et. al found that the efficacy of tazarotene 0.1% gel is clinically comparable to 0.1% tretinoin [in Retin-A Micro] and 0.025% gel tretinoin[Renova] and adapalene 0.1% gel [Differin].
Vitamin-A derivatives are thereby considered to be excellent prevention and treatment against the signs of aging caused by ultraviolet rays. However, the effects of vitamin A derivatives on sensitive skin can be harsh. As such, provided one is not breast-feeding, pregnant, or may become pregnant, s/he should talk to their dermatologist about making the right choice of tretinoin, retinol, or retinyl palmitate for a part of their anti-aging routine on a daily basis.
