Retinol and Other Acne Treatments Before, During, and After Pregnancy

I do not want to brag, but I was a very advanced adolescent, from a skin perspective. In fourth grade, when most kids were just dreaming of their first pimple, I was already sporting a full face of them. By fifth grade, I had advanced to dermatology appointments, where we iterated through the usual suspects: benzoyl peroxide wash, Retin-A, and tetracycline. None of them worked.

In sixth grade, though, I finally got to the good stuff: Accutane. I recall my doctor being somewhat reluctant to prescribe it, given my age. But he did, and it worked. It really, really worked. It was awful in some ways—I remember the skin on my lips just kind of flaking off—but also totally life-changing.

After a few months, my acne magically disappeared, allowing me to realize that the reason I was not popular was not, in fact, due to my acne. But I digress. From an acne standpoint, I stand by that it was magic.

I mention this because one thing I remember very distinctly from taking Accutane is that it came in a blister pack, and on the back of every single pill when you pushed it out, there was a little image of a pregnant woman with a big X through her—a daily reminder you should not take this if pregnant.

That clearly made its impression on me, but it’s been a long time since my Accutane days. What are the more recent developments (if any)? And what about topical retinol during pregnancy—which is used for acne but also for other skin issues—is that also off-limits?

Take me to the bottom line

Do not use Accutane while TTC and during pregnancy

Accutane is in a class of drugs called “retinoid.” (Accutane is a brand name; the molecule is isotretinoin, and it also comes in generic form). The molecule is closely related to retinoic acid, a vitamin A derivative that controls embryo development. Likely for this reason, exposure during pregnancy is associated with birth defects.

This association is extremely strong and scary and has been known for a long time. A 1985 paper in the New England Journal of Medicine reported on 154 pregnancies with Accutane exposure. Of these, 95 resulted in elective abortions. Of the remaining 59, there were 26 infants without significant birth defects, 12 miscarriages, and 21 infants with serious birth defects. This is an extremely high rate, and the birth defects were severe. As a result, Accutane as a drug is in pregnancy class X, and women taking it are required to be on birth control. You should absolutely not take Accutane if you are trying to conceive.

Pregnant women, even with serious acne, should never be prescribed Accutane (or any form of isotretinoin.) In fact, women who become pregnant accidentally while taking Accutane are often advised to terminate the pregnancy.

What acne medication can I use while TTC and during pregnancy?

On the other end, there are medications for acne that are considered safe in TTC and pregnancy. In particular, the most common (safe) option is topical (i.e., on the skin) benzoyl peroxide, either alone or in combination with an oral antibiotic (typically erythromycin or clindamycin). These two antibiotics are pregnancy “class B,” meaning they have been shown to be safe in humans. Benzoyl peroxide is class C, which means safety has been less concretely established, but we know that very little is absorbed into the system, and it is fully metabolized. The bottom line is that this combination is generally considered safe.

Then, in the middle, we have the most complicated issue: topical retinoids (often called retinol), which are drugs related (in molecular terms) to Accutane but used topically rather than ingested. There are two specific drug molecules: tretinoin (brands: Retin-A, Avita, etc.) and tazarotene (brands: Tazorac and Fabior). Tazarotene is pregnancy class X, meaning it would never be prescribed. But topical tretinoin is class C, which makes it more possible. The question is: is it a good idea?

Why is this complicated? On the one hand, we know that the oral retinoid form is really, really dangerous. This would naturally lead one to avoid these drugs in any form, oral or not. On the other hand, when you use a medicine on the skin, it absorbs much less into the bloodstream than when taken orally. And your body can metabolize the molecule safely in some concentration (it is present at some levels anyway). So, it is possible that retinoids are safe if used topically.

It is really a question for the data. And the data we have is, I would say, somewhat reassuring but very weak. A 2015 meta-analysis put together all the data we have on first-trimester exposure to retinoids (they focus on the first trimester because, generally, these are not prescribed, so most evidence comes from women who were accidentally exposed). Even after aggregating multiple studies, they came up with only 654 exposed women, whom they compared to 1,375 unexposed controls.

When they analyze outcomes like birth defects, miscarriage, stillbirth, and low birth weight, they do not find any significant evidence of a higher rate among exposed women. The problem is that their data are limited, so the confidence intervals are very large. For example, they find that exposed women are 20% more likely to have a baby with a significant birth defect. This is actually reasonably large, but from a statistical standpoint, they cannot reject that the two groups are the same. In fact, their estimates are consistent, with women being as much as 35% less likely or as much as 230% more likely. This is a very, very wide range.

In the end, the authors of this meta-analysis come down in what I think is a reasonable place on this. The combination of what we know about retinoids in oral form and the fact that we just do not have a lot of data leads them to suggest it’s not a good idea to prescribe these to pregnant women.

In turning to conception, if you know you are trying to conceive, the conclusions on pregnancy suggest you should stop the use of topical retinoids in advance. On the other hand, if you are using Retin-A and become pregnant by accident, it is not something to panic about.

What about acne medication while breastfeeding?

Many more skin treatments are considered safe during breastfeeding than while trying to conceive or during pregnancy. There are a couple of reasons for this. First, it is easier to test directly the passage of these substances through breast milk. You cannot directly see how much exposure a fetus is getting, but you can directly see how much is passing into breast milk. This allows for greater confidence. The second reason is that when you are pregnant, you share your blood supply with your baby, meaning that the levels of exposure in your blood are similar to theirs. When breastfeeding, the level of exposure in the breast milk mimics that in the mom’s bloodstream, but that gets diluted when consumed by the baby.

For these reasons, most acne treatments, including many oral medications, are considered safe during nursing. Accutane is an exception—there are no studies of this, but, typically, it is not recommended, likely as an extension of all of the pregnancy safety concerns.

Closing thoughts

If you are struggling with acne before or during pregnancy, some of the choices here are going to come down to your preferences. Like many aspects of pregnancy, there is a tendency here towards a “caution-at-all-costs” and “why-risk-it” approach. This approach may have you shunning all treatment—no antibiotics, benzoyl, etc. The data doesn’t suggest this is necessary; some treatments are safe. Moreover, this ignores the fact that acne can be debilitating, painful, and uncomfortable.

This last fact will lead some women to consider and use topical retinoids, which are, let’s face it, a lot more effective than benzoyl peroxide wash. And I will say that you can certainly find sources that take the above evidence to say that topical retinoids are safe. I do not think that’s an untenable position, but it does put a lot of weight on a very limited set of evidence.

The bottom line

Exposure to Accutane (isotretinoin) during pregnancy can result in birth defects. Due to the high risk, it is classified as pregnancy class X, requires birth control during treatment, and should be discontinued at least one month before attempting conception.
Topical benzoyl peroxide is generally safe during pregnancy, either alone or in combination with an oral antibiotic (typically erythromycin or clindamycin).
Topical retinoids, especially tretinoin (Retin-A), are more complex due to limited and inconclusive safety data. The combination of what we know about retinoids in oral form and the fact that we just do not have a lot of data leads them to suggest it’s not a good idea to prescribe these to pregnant women.
If you know you are trying to conceive, the conclusions on pregnancy suggest you should stop the use of topical retinoids in advance.
Most acne treatments (including many oral medications) are considered safe while breastfeeding. Accutane is an exception—there are no studies of this, but overall, it is not recommended, likely as an extension of all of the pregnancy safety concerns.