Is the ZO (Zo Skin Health) three-step peel, containing salicylic acid and retinol, safe for use during pregnancy?

ZO Three-Step Peel Safety in Pregnancy

The ZO three-step peel should be avoided during pregnancy due to the presence of retinol, which is contraindicated, while the salicylic acid component carries theoretical risks and requires careful consideration of application area and concentration. 1, 2

Critical Safety Concerns

Retinol Component - Contraindicated

• Topical retinoids (including retinol) are pregnancy category C and should be avoided during pregnancy due to the well-established teratogenic effects of systemic retinoids and theoretical concerns about topical absorption 1
• While one older study of topical tretinoin (a prescription-strength retinoid) showed no increased risk of major congenital anomalies (RR 0.7,95% CI 0.2-2.3), this does not establish safety for cosmetic retinol products used in chemical peels where absorption may differ 3
• The American Academy of Dermatology guidelines do not recommend topical retinoids during pregnancy, and systemic isotretinoin is known to cause severe congenital malformations 1

Salicylic Acid Component - Use with Extreme Caution

• Salicylic acid is FDA pregnancy category C, with animal studies showing teratogenicity in rats and monkeys, though extrapolation from oral doses to topical application is difficult 2
• The FDA label specifically states salicylic acid should be used during pregnancy "only if the potential benefit justifies the potential risk to the fetus" 2
• Critical safety threshold: Do not apply salicylic acid to more than 20% of body surface area to avoid systemic salicylate toxicity, which is particularly concerning during pregnancy 4
• The American Academy of Dermatology recommends "limited area of exposure and duration" for salicylic acid use during pregnancy 4

Clinical Algorithm for Decision-Making

Step 1: Assess the indication

• If treating acne during pregnancy, safer alternatives exist that are pregnancy category B 1, 5, 6

Step 2: Consider safer alternatives

• Azelaic acid 20% is pregnancy category B and offers comedolytic, antibacterial, and anti-inflammatory properties without the risks associated with retinoids 1, 5, 6
• Topical erythromycin is pregnancy category B for inflammatory acne 1
• Benzoyl peroxide can be used with appropriate precautions 1

Step 3: If chemical peel is deemed necessary

• Delay elective cosmetic procedures until after pregnancy and lactation 1
• The American Academy of Dermatology notes "limited evidence" for chemical peels in acne treatment, with results that are "not long-lasting" 1

Common Pitfalls to Avoid

• Do not assume "topical = safe": Chemical peels involve higher concentrations and prolonged contact time compared to leave-on products, potentially increasing systemic absorption 4, 2
• Do not combine with oral salicylate medications (including aspirin) due to additive systemic effects 4
• Avoid the misconception that cosmetic retinol is safer than prescription retinoids: The teratogenic potential of vitamin A derivatives applies across the class 1
• Most skin care products act locally with minimal systemic absorption, but chemical peels represent a different exposure scenario than routine cosmetic use 7

Breastfeeding Considerations

• If used during breastfeeding, salicylic acid should be limited to "localized use at mild concentrations" and avoided on the chest area 1, 4
• Retinoids should continue to be avoided during lactation when possible 1