Procedures and the pregnant patient

By Allison Evans, Managing Editor, May 1, 2025

With the ethical considerations on conducting clinical trials on pregnant and lactating women — and the often-limited data available on treatment safety — it’s no wonder that the safety of performing dermatologic procedures on these patients may seem murky.

Dermatologists discuss the safety considerations when performing dermatologic procedures on pregnant and lactating patients.

Cosmetics

“Dermatologists are typically a conservative group who like to make sure that what they’re doing is safe,” said Jenny Murase, MD, FAAD, associate clinical professor at the University of California, San Francisco and director of Medical Consultative Dermatology and Patch Testing at Palo Alto Medical Foundation. “The general rule of thumb is to postpone cosmetic procedures until after the baby is born.”

If a cosmetic procedure is going to be performed, it’s prudent to avoid higher-strength chemical peels because there could be a significant amount of systemic absorption, Dr. Murase said. It is more challenging to justify the use of hydroquinone and botulinum toxin for strictly cosmetic purposes during pregnancy, she added.

Hydroquinone has a high degree of systemic absorption (35-45%) with a lack of extensive human studies. Although both preclinical and small human cohort studies have not found any mutagenic or teratogenic properties with its use, the generalizability of the studies are uncertain, according to a 2024 JAAD CME article.

According to the same article, the use of botulinum toxin should be limited given the lack of definitive safety data during pregnancy as well. However, preclinical studies suggest it does not cross the placenta, and clinical reports examining the use of botulinum toxin during pregnancy have not identified significant adverse maternal fetal complications.

“Botox has been used extensively within the neurologic community for recalcitrant headache, and it doesn’t look like there are any safety signals; however, it’s hard to justify the exposure for wrinkles during the short time a patient is pregnant,” Dr. Murase said.

Potential skin cancers

Like many dermatologists, Naissan Wesley, MD, FAAD, FACMS, director of Mohs Surgery, Skin Care and Laser Physicians of Beverly Hills, California, recommends delaying elective procedures or surgeries during pregnancy, if possible, but continuing to treat skin cancers during pregnancy as per the standard of care.

The second trimester is the safest time to perform procedures, said Jane Grant-Kels, MD, FAAD, professor of dermatology, pathology, and pediatrics, and director of the Cutaneous Oncology Center and Melanoma Program at UConn Health. “However, if a patient comes in with a concerning skin lesion, I’m going to biopsy it immediately; the risk is very minimal.”

“When a patient is seen for a concerning lesion, you treat your pregnant patient the same way you treat the non pregnant patient.”

“When a patient is seen for a concerning lesion, you treat your pregnant patient the same way you treat the non-pregnant patient,” Dr. Murase agreed. “There should be no assumption that moles are supposed to change in pregnancy.”

“If a lesion is becoming red or having an atypical pigment network, that’s something that should not be happening. Anything beyond skin stretching changes needs to be biopsied to find out whether it may be an atypical melanocytic lesion or a potential skin cancer. The biopsy should not be delayed until after pregnancy,” she noted.

“If it’s a basal cell carcinoma and you want to wait until the second trimester, or if the woman is near the end of her pregnancy and you want to wait until she delivers, that is acceptable as basal cell carcinoma has a low risk,” said Dr. Grant-Kels. “Of course, this also depends on the size and location of the lesion. In general, I’m not timid about doing biopsies, and there have been recommendations by the American Academy of Dermatology that state it is certainly allowable to do procedures.”

“Rather than using a topical chemo or immunotherapy, I would choose to treat with surgery, when possible,” she added.

Melanoma

Melanoma is one of the most common malignancies that occur during pregnancy. In fact, malignant melanoma is one of the most common malignancies to affect young women, and approximately one-third of all women diagnosed are of childbearing age. As women trend toward delaying childbearing into their 30s and 40s, the number of melanomas during pregnancy is expected to rise.

“If the lesion is a stage 3 or 4 melanoma, we have to treat systemically,” Dr. Grant-Kels said. “In the past you could treat with chemo, although now it’s been shown that chemo doesn’t work as well as the new targeted therapies.”

“Unfortunately, the newer targeted therapies are considered potentially teratogenic. You have to wait until the woman has given birth, or potentially try to deliver the child early, before initiating these targeted treatments,” Dr. Grant-Kels said. “Also, I would advise them not to breastfeed if they require to be treated systemically with one of the targeted therapies.”

“If scans are needed, we recommend avoiding dyes and if an MRI is indicated, we recommend waiting until the second trimester and not using gadolinium,” Dr. Grant-Kels added. “With CAT scans, I would do them without IV contrast mostly because of concern about an adverse reaction to the dye.”

If a woman has been treated for metastatic melanoma with the newer, targeted therapies and wants to become pregnant, they have to wait several weeks to months depending upon the drug after the last dose before considering pregnancy or lactation. “I generally advise these patients to wait two to three years before they consider pregnancy because melanoma is one of the cancers that can metastasize to the placenta,” Dr. Grant-Kels said. “However, we evaluate each patient on a case-by-case level.”

Although local excision of melanomas can be performed safely during pregnancy, sentinel lymph node biopsy during pregnancy is controversial due to potential fetal harm from radiation exposure from the radioactive tracer used as well as, to a lesser extent, the potential effects of blue dye.

Dr. Grant-Kels said, “If necessary, the ideal time for sentinel lymph node biopsy would be to wait until the second trimester although some institutions recommend waiting until after the pregnancy. It can be postponed if a woman is in her third trimester or a few weeks away from delivery. You have to use your judgement.”

Local anesthetics

Pregnancy classes A, B, C, D, and X have gone out of style with the FDA’s Pregnancy and Lactation Labeling Final Rule that went into effect June 2015. In its place are narrative sections and subsections, including “Pregnancy Exposure Registry, Risk Summary, Clinical Considerations, and Data,” — which contains increased detail but also increased complexity.

The former pregnancy classes were often misleading, particular B and C, said Dr. Murase. “For example, as a new medicine you could pretty easily get a B class designation while an older drug may receive a C designation because they had been around longer, which meant more studies were performed.” The fact that lidocaine, a medicine that has been around a long time, remained category B for as long as it did really speaks to its safety, Dr. Murase explained.

“Epinephrine, which is used in such minuscule doses for dermatologic surgery, may result in a small amount of vasoconstriction in the local area. It’s reducing the risk of any anesthetic getting to the fetus,” Dr. Murase noted.

“The biggest risk is general anesthesia, which we try to avoid during the first trimester, and also third trimester because it can induce premature labor.”

Some dermatologists choose not to use epinephrine. “Although epinephrine can theoretically cause some contractions in the uterus, its advantage is that it constricts blood vessels locally,” Dr. Grant-Kels said. “If a patient is nervous about using epinephrine, I’ll use the lidocaine without the epinephrine.”

“For use of local anesthetic for a biopsy or skin cancer surgery, I will use lidocaine without epinephrine, and counsel the patient that they may potentially experience slightly more bleeding or bruising during and after the procedure without the epinephrine, and to take it easy the first 48 hours after the procedure when the bleeding risk is the highest,” Dr. Wesley said.

Dr. Murase explained that when using lidocaine or lidocaine with epinephrine, catecholamines are inactivated at the placenta. This means that when a woman’s heart rate goes up, that does not mean the baby’s heart rate goes up in response. At the small doses used in dermatologic surgery, it is likely safe, she said.

It is recommended to avoid intra-arterial injection of local anesthetic and high concentrations to limit fetal cardiac toxicity, Drs. Grant-Kels and Murase stated in the 2024 JAAD CME article. “The biggest risk is general anesthesia, which we try to avoid during the first trimester, and also third trimester because it can induce premature labor,” Dr. Grant-Kels said. “But it’s ultimately a risk-benefit ratio, and if the mother’s life is at risk, then you do what has to be done.”

Laser treatments

Patients with vitiligo, psoriasis, and other conditions may undergo treatments with an excimer laser or pulse-dye laser, which are generally accepted to be safe. “There is no research to suggest these laser treatments would be contraindicated,” Dr. Murase said. “But, again, do you want to just wait a few months as opposed to doing it during pregnancy? That’s a decision that the patient and dermatologist have to make.”

“For psoriasis, in particular, a lot of the biologics we use are considered safe,” Dr. Grant-Kels added, “so I think laser treatments could be deferred when there are alternative therapies available.”

When treating pregnant patients, everything is a risk-benefit, Dr. Grant-Kels said. “I’m not going to perform cosmetic procedures, but for diseases like psoriasis, atopic dermatitis, and skin cancer, I think it’s appropriate to treat them as long as you check that any medications you may be using are in a category that has been studied in pregnant women. There are many skin diseases that need to be treated.”

Additional DermWorld Resources