Common skin and hair changes in pregnancy and how to manage

06/2024

Changes to your skin, nails, and hair are common during pregnancy due to hormonal alterations, and vascular, metabolism, and immunologic changes during pregnancy. Here are few things you may experience and what can be done to manage them!

SKIN

Dark spots and melasma

Melasma

Dark spots and patches on your skim are caused by an increase in the body’s melanin. Melasma (ie, chloasma or mask of pregnancy) occurs in up to 75% of pregnant people and causes hyperpigmentation of the face. These dark spots and and darker patches of the skin usually fade on their own after birth. However, some dark patches can last for years. To help prevent melasma from getting worse, you should wear sunscreen (SPF of 50+) and a wide-brimmed hat when you are outside. Mineral sunscreen (titanium oxide and zinc oxide) are the best choices. Chemical type sunscreens with benzophenone-3 (oxybenzone) are absorbed systemically and should be used with caution in pregnancy.

Treatments for dark spots and melasma in pregnancy include:

  • Topical kojic acid
  • Azelaic acid
  • Glycolic acid

Postpartum treatments include:

  • Topical skin-lightening agents, oral tranexamic acid, chemical peels, and laser and light therapies

Hyperpigmentation

Hyperpigmentation

Almost all pregnant people develop increased skin pigmentation in various areas of the body. In fact, it is the most common skin lesion and affects up to 90% of pregnant individuals of all skin tones. The increased pigmentation usually occurs in discrete, localized areas. Why this occurs is not completely understood. We do know that estrogens and progesterone cause melanocytic stimulation. However, the pigmentary changes occur early in pregnancy and before the elevation in alpha-melanocyte stimulating hormone plasma levels, which occur in late gestation.

Types of hyperpigmentation include:

  • Darkening of facial skin (ie, melasma)
  • Darkening of the midline skin (ie, linea nigra)
  • The periareolar skin also darkens and extends outward in a net-like array, referred to as the secondary areola
  • Other areas include the nipples, axillae, genitalia, perineum, anus, inner thighs, and neck
  • A darker hue of recent scars, freckles, and lentigines

Treatment in pregnancy can include:

  • Alpha hydroxy acid (AHA) concentration up to 10% with pH > 3.5
  • Azelaic acid after the first trimester

Postpartum treatmens include:

  • Topical therapies: hydroquinone, azelaic acid, mequinol, kojic acid, tretinoin, and combinations of topical agents
  • Chemical peels and laser therapy

Stretch marks

Stretch Marks

As your belly grows during pregnancy, your skin may become marked with reddish lines called stretch marks. By the 3rd trimester, stretch marks can be on the abdomen, buttocks, breasts, or thighs. Using a heavy moisturizer may help keep your skin soft, but it will not help get rid of stretch marks. Most stretch marks fade after the baby is born, but they may never disappear completely. Many persons may use a wide variety of creams, lotions, and ointments in attempts to reduce risk for striae development, but strong evidence to confirm efficacy of any of these interventions is lacking. Don't waste your money!

During pregnancy it is best to stay hydrate and use a good moisturizer. Safe ingredients in moisturizers include AHA, ammonium lactate, organic silica, phospholipid, cholesterol, fatty acid, propylene glycol, glycerin, and sorbitol.

Postpartum treatments include topical tretinoin and various laser therapies.

Acne

Acne

Hormonal changes in pregnancy can contribute to the development of acne, even if you have never had a problem with it before! An increase in androgens is thought to be a primary cause. Pregnancy acne is typically inflammatory an can even occur on your chest and back. Data is largely lacking on the safety of medications for the treatment of acne in pregnancy, but there are some options available to those who need treatment.

If you get acne during pregnancy, take these steps to treat your skin:

  • 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 acne sores to lessen possible scarring.
  • Choose oil-free cosmetics.

These products and medications can be used during pregnancy:

  • Topical benzoyl peroxide, azelaic acid, salicylic acid, glycolic acid
  • Topical clindamycin, erythromycin, metronidazole or dapsone
  • Intralesional steroid injections
  • Oral erythromycin, amoxicillin, cephalexin, azithromycin, clindamycin
  • Chemical peels
  • Laser and light therapy

Some products and medications should not be used in pregnancy:

  • Hormonal therapy
  • Spironolactone
  • Isotretinoin & tetracyclines
  • Topical tazarotene
  • Topical retinoids (ie adapalene, tretinoin, trifarotene)

Varicose veins

Lower Extremity Varicose Veins

The weight and pressure of your uterus can decrease blood flow from your lower body and cause the veins in your legs to become swollen, sore, and blue. Varicosities can also appear on your vulva and in your vagina and rectum (hemorrhoids). In most cases, varicose veins will go away after delivery, but up to 50% of pregnant people experience abnormal dilation of the superficial veins of the lower extremities that persist.

Varicose veins are most common in the 3rd trimester with anorectal varicosities (hemorrhoids) affecting up to 70% of pregnant patients. Vulvar varicosities can cause something known as "Jacquemier's sign"--venous distention in the vestibule and vagina associated with vulvar varicosities. This area may appear like a "bag of worms" in the enlarged labia and may be associated with pelvic congestion syndrome.

Things you can do to ease the swelling and soreness:

  • Don’t sit with your legs crossed for long periods
  • Prop your legs up on a couch, chair, or footstool as often as you can
  • Exercise regularly—walk, swim, or ride an exercise bike.
  • Wear support hose
  • Avoid constipation by eating foods high in fiber and drinking liquids
  • Don't sit or stand for long periods of time

Treatments available:

Leg varicosities

  • Supportive therapy: leg elevation, compression hosiery, sleeping on the left side, exercise, and avoidance of long periods of standing or sitting.
  • Medical or surgical intervention can be considered 3-6 months after delivery and depends on the clinical severity and nature of underlying venous reflux, as well as the patient's future childbearing plans.

Hemorrhoids

  • Local application of antiinflammatory, antipruritic, and local anesthetic preparations.
  • Adequate hydration and a diet with fiber may reduce constipation, which aggravates discomfort.
  • Recurrent and severe hemorrhoids usually require surgical treatment with hemorrhoidectomy, which can be performed safely duringpregnancy if necessary.

Vulvar varicosities

  • During pregnancy, they are managed conservatively by vulvar support and compression and by avoiding prolonged standing.
  • Symptomatic varicosities that don’t resolve postpartum can be treated by sclerotherapy, excision, embolization, and ligation.

HAIR

The hormone changes in pregnancy may cause the hair on your head and body to grow and/or become thicker. Sometimes hair can even grow in areas where you do not normally have hair, such as the face, chest, abdomen, and arms due to increased androgens. Hirsutism, excessive growth of dark or coarse hair in a male-like pattern, can occur on the face, chest and back, arms, legs, and suprapubic region. This occurs due to increased levels of ovarian and placental androgens on the pilosebaceous unit. Scalp hair often appears thicker or denser due to slowing of the normal progression of hairs from anagen (growing stage) to telogen (resting stage). Rarely, late in pregnancy, hair in the frontoparietal area recedes in a mild form of androgenic alopecia.

In the postpartum period, hormones return to normal, allowing the hair to return to its cycle of growing and falling out. Excessive hair shedding of the scalp (telogen effluvium) starts 1-5 months postpartum and is caused by falling estrogen levels--it is temporary. Most people see their hair return to its normal fullness by their child’s first birthday or even earlier. In some, the scalp hair may never be as dense as it was prior to pregnancy.

Hair Dyes

Permanent hair color products contain phenylenediamine, 3-aminophenol, resorcinol, toluene-2,5-diaminesulphate, sodium sulfite, oleic acid, sodium hydroxide, ammonium hydroxide, propylene glycol, and isopropyl alcohol. Experimental animal studies showed risks of teratogenicity of phenylenediamine, aminophenols, and ethanolamine, when used in very high doses. However, there is very limited systemic absorption in human studies. As a result, these chemicals are very unlikely cross the placenta. Due to the limited data, it is best to avoid hair dye in the first trimester.I

Postpartum hair loss tips:

  • Use a volumizing shampoo. These shampoos tend to contain ingredients like protein that coat the hair, making the hair appear fuller.
  • Continue your prenatal vitamins.
  • Avoid any shampoo labeled “conditioning shampoo”: contain heavy conditioners that weigh down hair and make it look limp.
  • Use a conditioner formulated for fine hair: contain lighter formulas that wont weigh down hair.
  • Use conditioner primarily on the ends of your hair:Applying conditioner to your scalp and all of your hair tends to weigh down hair.
  • Avoid conditioners labeled “intensive conditioners" as these are too heavy.

Tips for BIPOC:

  • Be careful with your hairstyles.
    • Low manipulation, protective hairstyles are recommended.
    • Give your hair a break and try braids or flat twists.
    • If you have locs, vary hairstyles and consider the tension you’re putting on your hair when styling and locking your roots.
  • Keep hair loose.
    • Avoiding tight hairstyles and headbands.
    • Keep it loose and avoid things that will pull or be heavy on your hair and edges.
    • Sleep with a protective bonnet/scarf or satin pillowcase.
  • Keep a good hair routine.
    • Try castor oil scalp massages.
    • Avoid harsh gels or mousses.
    • Washing less will not help with postpartum hair loss.
    • Instead try to keep to a simple hair routineof cleansing,moisturizing and styling your hair.
    • Use a mild shampoo and conditioner and please avoid chemicals and heat!

Please check out my website for other important pregnancy topics!

You can also read this recent review that provides an updated reference to aid patient-physician decision-making on acne management. Another great article is here!

Frequently Asked Questions

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I am a double board certified ObGyn and Maternal-Fetal Medicine Specialist. I have worked at a large academic center in academic medicine as a clinician, educator and researcher since 2004.  I am currently a tenured Professor and actively manage patients with high-risk pregnancies.

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