What is the management of rosacea (acne rosacea) exacerbation to a full-body rash during pregnancy?

From the Guidelines

Managing rosacea during pregnancy that has progressed to a full-body rash requires careful treatment with azelaic acid (Finacea 15% gel, applied twice daily) as the first-line topical treatment, due to its safety profile and efficacy in reducing inflammatory lesions, as supported by recent studies 1. For immediate relief, use gentle, fragrance-free cleansers like Cetaphil or CeraVe and apply cool compresses to inflamed areas. It is essential to consult with both a dermatologist and obstetrician before starting any treatment to ensure the best possible outcome for both the mother and the developing baby. Some key considerations for managing rosacea during pregnancy include:

• Avoiding oral antibiotics like doxycycline and isotretinoin, which are contraindicated during pregnancy
• Using low-potency topical steroids like hydrocortisone 1% for short-term use on limited body areas
• Avoiding known triggers such as spicy foods, hot beverages, alcohol, extreme temperatures, and harsh skincare products
• Wearing broad-spectrum SPF 30+ sunscreen daily
• Staying hydrated
• Managing stress through relaxation techniques Hormonal changes during pregnancy often exacerbate rosacea, but symptoms typically improve after delivery. If the rash is severe, spreading rapidly, or accompanied by other concerning symptoms like fever or blistering, seek immediate medical attention as this could indicate a different condition requiring specialized treatment, as recommended by recent guidelines 2. Topical azelaic acid has been shown to be effective in improving rosacea by exerting anti-inflammatory activity on the cathelicidin pathway, which is upregulated in rosacea-affected skin 1. Additionally, metronidazole 0.75% and 1.0% formulations have been well studied and are effective in reducing inflammatory lesions and perilesional erythema associated with rosacea, but their use during pregnancy should be carefully considered and monitored 3.

From the FDA Drug Label

Pregnancy: Teratogenic Effects: Pregnancy Category B Embryotoxic effects were observed in Segment I and Segment II oral studies with rats receiving 2500 mg/kg/day of azelaic acid. Similar effects were observed in Segment II studies in rabbits given 150 to 500 mg/kg/day and in monkeys given 500 mg/kg/day. The doses at which these effects were noted were all within toxic dose ranges for the dams. No teratogenic effects were observed There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

The management of rosacea exacerbation to a full-body rash during pregnancy is not directly addressed in the provided drug labels.

• Key consideration: Azelaic acid should be used during pregnancy only if clearly needed 4.
• Clinical decision: Due to the lack of direct information, a conservative approach would be to consult a physician for guidance on managing rosacea exacerbation during pregnancy.

From the Research

Management of Rosacea Exacerbation During Pregnancy

• The management of rosacea exacerbation to a full-body rash during pregnancy poses a significant challenge due to the limited evidence regarding the safety and efficacy of various treatments 5.
• Topical metronidazole has been used successfully in combination with other therapies to treat rosacea fulminans (RF) in pregnant women 5.
• Azithromycin is considered a safe oral rosacea therapy for pregnant patients and has been used to treat RF 5.
• The pregnancy categories of various rosacea treatments should be reviewed, and algorithms developed for treating pregnant patients with rosacea and RF 5.

Treatment Options for Rosacea

• Topical medications, such as ivermectin, metronidazole, and azelaic acid, are recommended as first-line treatments for patients with erythematous and mild to severe papulopustular rosacea 6.
• Brimonidine is approved for the treatment of erythema, while ivermectin, metronidazole, and azelaic acid are approved for the treatment of inflammatory lesions 6.
• Systemic therapy, such as tetracyclines and metronidazole, may be used to treat papulopustular rosacea, but their safety and efficacy during pregnancy are limited 7, 8.

Rosacea During Pregnancy

• Acne and rosacea are common chronic inflammatory skin diseases that may become aggravated during pregnancy 9.
• Up to 42% of pregnant women suffer from acne, and 60% experience deterioration of acne during pregnancy 9.
• There are no randomized controlled trials for the treatment of acne or rosacea during pregnancy, and current guidelines recommend modifying treatment options to minimize harm to the embryo or fetus 9.