Are topical corticosteroids (CS) safe to use during pregnancy?

From the Guidelines

Topical corticosteroids can generally be used during pregnancy when medically necessary, with preference for lower-potency options when possible, as they have a favorable safety profile due to limited systemic absorption. According to the most recent and highest quality study, modern nasal corticosteroids including budesonide, fluticasone, and mometasone should be safe to use for CRS maintenance during pregnancy at recommended doses 1. The use of topical corticosteroids during pregnancy should prioritize the control of maternal sinonasal inflammation and quality of life while ensuring fetal safety.

Key Considerations

• Mild to moderate potency corticosteroids like hydrocortisone (0.5-1%), desonide, or triamcinolone are considered safer first choices for pregnant women.
• These should be used at the lowest effective dose, for the shortest duration needed, and on the smallest affected area possible to minimize systemic absorption.
• Higher potency corticosteroids like betamethasone or clobetasol should be reserved for severe conditions that don't respond to milder options, and used for brief periods only.
• Avoid applying topical steroids on large body surface areas or under occlusion during pregnancy, as this increases absorption.

Evidence Base

The safety of topical corticosteroids in pregnancy is supported by studies such as the one by Ellegard et al., which evaluated fluticasone propionate nasal sprays in pregnant women with rhinitis and found no detectable influence on maternal cortisol or fetal growth 1. Additionally, the European position paper on rhinosinusitis and nasal polyps 2020 recommends the continued use of nasal corticosteroids during pregnancy due to their safety profile 1.

Clinical Judgment

Clinical judgment must be exercised when considering the use of topical corticosteroids during pregnancy, weighing the benefits of controlling maternal symptoms against the potential risks to the fetus. However, the current evidence suggests that topical corticosteroids can be safely used when medically necessary, with appropriate precautions and monitoring. Always inform your healthcare provider about pregnancy status when topical corticosteroids are prescribed.

From the FDA Drug Label

Corticosteroids are generally teratogenic in laboratory animals when administered systemically at relatively low dosage levels. The more potent corticosteroids have been shown to be teratogenic after dermal application in laboratory animals There are no adequate and well-controlled studies in pregnant women on teratogenic effects from topically applied corticosteroids. Therefore, topical corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Drugs of this class should not be used extensively on pregnant patients, in large amounts, or for prolonged periods of time

Topical corticosteroids are not considered safe to use during pregnancy without caution. The potential benefit must justify the potential risk to the fetus, and their use should be limited, not extensive, and for short periods of time 2.

From the Research

Safety of Topical Corticosteroids in Pregnancy

• The use of topical corticosteroids during pregnancy has been studied in several research papers, with most finding no significant associations between maternal exposure to topical corticosteroids of any potency and adverse pregnancy outcomes 3, 4, 5, 6, 7.
• A study published in the Journal of Investigative Dermatology found no associations between maternal exposure to topical corticosteroids and orofacial cleft, preterm delivery, and fetal death, but did find a significant association with fetal growth restriction 4.
• Another study published in the Journal of the European Academy of Dermatology and Venereology found no significant associations between maternal use of topical corticosteroids of any potency and adverse pregnancy outcomes, including mode of delivery, birth defect, preterm delivery, and fetal death 5.
• A cohort study published in JAMA Dermatology found no association between topical corticosteroid use in pregnancy and an increased risk of small for gestational age or low birth weight 6.
• A systematic review published in the Cochrane Database of Systematic Reviews found no causal associations between maternal exposure to topical corticosteroids of any potency and pregnancy outcomes, including mode of delivery, congenital abnormalities, preterm delivery, fetal death, and low Apgar score 7.

Potency of Topical Corticosteroids

• Some studies suggest that potent or very potent topical corticosteroids may be associated with an increased risk of low birth weight or fetal growth restriction 4, 5, 7.
• However, other studies have found no association between the use of potent or very potent topical corticosteroids and adverse pregnancy outcomes 6.
• The European Dermatology Forum guideline recommends that mild or moderate potency topical corticosteroids should be preferred to potent or very potent ones in pregnancy 5.

Clinical Implications

• Topical corticosteroids can be used safely and effectively in patients who are pregnant or lactating, but the quantity and potency of the corticosteroid prescribed should be carefully considered 3.
• Patients should be taught correct application techniques, such as the fingertip unit method, to minimize the risk of adverse effects 3.
• Healthcare providers should be aware of the potential risks and benefits of topical corticosteroid use in pregnancy and monitor patients closely for any adverse effects 4, 5, 6, 7.