Categorization of procedures

Dermatologic procedures during pregnancy can be divided into three categories: urgent, nonurgent, and elective. Urgent procedures include taking a biopsy and/or treating a lesion suspicious of melanoma or an aggressive nonmelanoma skin cancer. A friable, bleeding pyogenic granuloma also needs to be managed promptly. Nonurgent procedures include procedures such as treating a nodular BCC, which may be undertaken during the second trimester. Lastly, elective procedures are those which can be deferred until after delivery, such as scar excision and chemical peeling and other cosmetic procedures.[1]

Injectable local anesthetics

The commonly used injectable anesthetics are as follows:

Lidocaine, prilocaine, etidocaine (pregnancy Category B);

Bupivacaine and mepivacaine (pregnancy Cat C).[8]

Bupivacaine and mepivacaine are not indicated in pregnancy unless the potential benefits outweigh the risks. Mepivacaine is associated with fetal bradycardia, preterm labor, and twice the incidence of congenital abnormalities.[813]

What is the risk?

Local injectable anesthetic (predominantly lignocaine) usage during pregnancy leads to an estimated 11%–23% exposure to the fetus.[8] A relative acidosis with poor protein binding increases the free drug exposure to the fetus.[14] However, this exposure may not always cause toxicity as the fetal liver is well capable of metabolizing lignocaine.[15]

Pregnancy-induced rise in progesterone enhances the membrane sensitivity of nerves to local anesthetics (LA), thereby lessening the required anesthetic dosage in early pregnancy.[14] Rarely, lignocaine toxicity arises when there is accidental arterial injection or excessive high doses being used (>4.5 mg/kg up to a maximum of 300 mg, which is rare in dermatologic procedures).[810,1316] The symptoms of lignocaine toxicity mimic aortocaval compression syndrome such as dizziness, tachycardia, agitation, headaches, sweating, and cephalea.[24,10]

Once these symptoms appear in the mother, chances of fetal exposure increase in the form of cardiac or central nervous system (CNS) toxicity.[78] There is a theoretical risk of inhibiting neutrophil chemotaxis, cell division, and neural development in the newborn when LA concentration exceeds 100 μg/mL.[1718]

To decrease the systemic spread of LA, adrenaline (Cat C) is used alongside lignocaine. Although this increases the safety profile of LA, inadvertent intra-arterial absorption of high doses of adrenaline could lead to uterine artery spasms resulting in fetal compromise and prematurity. Thankfully, the doses used in dermatologic indications are very low with a high dilution of 1:200,000 which negates this risk.[810,1920] Safe use of lignocaine with adrenaline in pregnant and lactating women has been documented.[21]

In a study, 210 pregnant women were analyzed for adverse pregnancy outcomes who underwent dental procedures with lignocaine. They reported a slight but insignificant increase (4.8% vs. 3.3%) in adverse fetal outcomes (such as septal cardiac anomalies, cerebral palsy, twin-to-twin transfusion syndrome, Turner syndrome, cleft lip and palate, umbilical hernia) compared to control population.[22]

Therefore, lignocaine with or without adrenaline is considered the safest option to provide local injectable anesthesia.

Topical anesthesia

Different forms of topical anesthetics are available such as EMLA cream (lidocaine 2.5% + prilocaine 2.5%), EMLA anesthetic disc (lidocaine 2.5% + prilocaine 2.5%), ELA-Max topical anesthetic cream (lidocaine 4% cream), and Lidoderm (lidocaine 5% patch).[23] Unlike injectable forms, topical creams are considered much safer. However, anecdotal reports advise us to be vigilant with some topical agents as follows:

1. Prilocaine in high doses holds a risk of methaemoglobinemia in the fetus, because of which, lidocaine-prilocaine (both Cat B) cream should be used in moderation.[24] Occlusion should be avoided as should the use near periocular and mucosal surfaces, as this can increase systemic absorption and irritation.[1625,26] Tetracaine is the preferred topical anesthetic for periocular procedures because of its low risk of irritation.[2526]

2. Tetracaine and benzocaine (both Cat C) are associated with fetal methaemoglobinemia.[2527]

Therefore, a lidocaine/prilocaine mixture (in moderation) is the preferred choice for topical anesthesia and for those concerned about its safety profile, liposomal lidocaine can be used as it provides a longer duration of anesthesia than nonliposomal preparations.[1626]

Electrocautery and radiofrequency

Electrocautery is considered harmless to the fetus when used in the mother. However, measures should be taken to reduce smoke plume exposure which can be mutagenic and carcinogenic.[28] This risk is the same for both nonpregnant and pregnant patients by extension to the fetus.[826] Masks are considered poor barriers for this plume; therefore, a smoke evacuator is preferred for reducing smoke exposure.[4]

Intralesional steroid injections

Intralesional steroid in hypertrophic scars, keloids, and alopecia areata is not recommended until benefits outweigh risk, as corticosteroids are considered Cat C and have been reported to cause cleft lip and palate, along with the risk of hypoadrenalism in newborns.[29]

Lasers

The limited data available suggest safe use of most lasers in pregnancy.

Chemical peeling

Energy-based devices (lasers, IPL, and electrosurgery)

As already mentioned above, theoretically, lasers for cosmetic purposes act on the very principle of selective photothermolysis, which prevents their action to go beyond the deep dermis, thereby precluding any harm to the fetus. Still, due to a lack of satisfactory safety data, cosmetic lasers should be avoided until after the delivery.

Hair removal by means of laser, IPL, or electrolysis is not recommended due to unavailability of safety data. The hormonal changes continue to stimulate new hair growth, leading to unsatisfactory treatment responses.[6] Also, amniotic fluid is considered to be a good conductor of galvanic current, which poses risk to the fetus during electroepilation.[7] Women are recommended to treat excess hair using waxing, shaving, threading, and chemical depilation.[67]

Treatment of striae during pregnancy lack evidence-based trials. PDL has shown some promising results, but it is recommended to wait until postpartum period to start any treatment.[5051] After delivery, different ablative (CO₂ fractional laser)[52] and non-ablative (1540 nm Er-doped glass fractional nonablative,[53] PDL,[5051] Nd:YAG,[54] and copper bromide[55]) lasers have been tried with varying results.

Platelet-rich plasma therapy for hairloss

The hormonal fluctuation during gestation causes the anagen phase of hair cycle to be prolonged leading to hair looking fuller and healthy. Upon childbirth, there is a major shift to telogen phase causing increased hairfall and thinning. In maximum cases, the hair cycle normalizes within about a year. Therefore, Platelet Rich Plasma therapy which involves extracting and concentrating platelets from whole blood and injecting them into the scalp is only beneficial post-delivery and is not indicated in pregnancy, with an added risk of sepsis, putting the fetus at risk.[5657]

Botulinum toxin

Botulinum toxin type A has been used for both cosmetic and medical indications.[58] Correct intramuscular or intradermal administration of botulinum toxin does not lead to significant systemic concentrations.[58] Furthermore, the size of the toxin molecule prevents it from crossing the placental barrier.[5859] The doses used in aesthetic purposes (up to 100U) are significantly lower than the hazardous doses of 600U.[59] Further in one study on pregnant women who contracted botulism while being treated with onabotulinum antitoxin, all have been reported to deliver normal healthy children suggesting that both the toxin and antitoxin possibly does not cross the placenta.[660]

Case reports are available where the toxin has been used for medical indications such as achalasia, cervical dystonia, and migraine prophylaxis during pregnancy.[16] No complications (such as infant neuromuscular blockade or weakness)[25] have been noted in the delivery or health of the infants born to these mothers even after few years.[616263] A single case of a 39-year-old pregnant woman who had a twin pregnancy miscarriage at ten weeks is reported. She received 500U of onabotulinum toxin at 4 weeks of gestation for cervical dystonia. The woman was on concomitant benztropine (Cat C), clonazepam (Cat D), and fluoxetine (Cat C) during the toxin injection. She also had a history of one miscarriage prior to this episode. It is difficult to determine whether the toxin had any role to play in the fetal demise, as she had many collateral risk factors associated with the same.[64]

In a report, botulinum toxin type A was used for cosmetic indications in two pregnant women and the authors did not observe any fetal adverse effects.[6566]

Studies exploring use of abobotulinum and incobotulinum toxin are lacking and also secretion of toxin into breast milk is unknown.[2567]

Botulinum toxin type A is a Cat C drug and in view of the above inconclusive data, more research is needed to make a concrete statement on its cosmetic usage in pregnancy and is recommended to be avoided in the present scenario.

Fillers

The most commonly used cosmetic filler is hyaluronic acid, which has much similarity with the intrinsic hyaluronic acid of the human body. This property makes it a safe compound to be injected into the skin during pregnancy. However, lignocaine (the amount used is far lower than recommended maximum dosage), is generally mixed with the filler, and this needs to be taken into consideration, as discussed previously.[68]

Theoretically, fillers rarely may cause hypersensitivity or injection site infection.[69] Also, after injecting a filler, there is some local inflammation followed by collagen remodeling. Vascularity is also increased and there is increased susceptibility to hyperpigmentation encountered in pregnancy.[4] Looking upon these issues, manufacturer recommendations include fillers in pregnancy as a relative contraindication.

Sclerotherapy

Varicose veins that develop during pregnancy, have high chances of resolving within 6–12-month postpartum.[70] A divided opinion exists in the literature, where the German Society of Phlebology and Rabe et al. suggested that sclerosants can cross the placenta and are absolutely contraindicated in pregnancy.[7071] On the other hand studies done by Abramowitz[72] and Reich-Schupke et al.[73] showed that sclerotherapy is a safe procedure in pregnancy and no complications were observed in either the mother or the baby. Of all the commonly used agents (i.e., sodium tetradecyl sulfate, polydocanol, and hypertonic saline), hypertonic saline is considered to have the lowest risk of causing adverse reactions.[25] A very limited data over safety of sclerosants in pregnancy prevents us from making a concrete statement about whether they can be used during gestation or not.

Miscellaneous

When to perform a procedure?

Dermatological procedures, in general, should be conducted preferably during the second trimester or the postpartum period, because the first 12 weeks of gestation are critical for organogenesis and increases the risk of spontaneous abortion, whereas surgery during the third trimester may predispose to premature delivery.[110]

Antibiotics

Surgical resection of tumors and malignant lesions

Commonly seen tumors and malignant lesions in pregnancy are nevi, pyogenic granuloma, dermatofibroma/dermatofibrosarcoma, melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC).[421]

During pregnancy, surgical intervention for malignant lesions is most likely to be performed for melanoma (95%), followed by SCC (67%), and least likely for BCC (45%).[21] Second trimester is considered to be the optimal period for surgical intervention; however, under local anesthesia, surgery can be performed in any trimester.[21]

Benign nevi may undergo morphological changes in gestation such as an increase in size and/or pigmentation[79] along with dermoscopic alterations like new dot formation (6%), thicker pigment network, dark globules, and an increase in vascularity which may revert to normal post-delivery.[80] These changes, regardless of pregnancy state, warrant immediate biopsy.[481]

Melanoma accounts for 8% of all malignancies diagnosed in pregnancy and has a poor prognosis.[121,82] Although transplacental transmission is unusual, melanoma represents 31% of metastases to the placenta and 58% of those involve the fetus.[182] Fetal involvement is always associated with placental involvement, but vice versa may not be true.[83] In another study, 27 cases of melanoma involving the placenta were reported, out of which 22% (i.e., six cases) were transmitted to the fetus and developed melanoma in the infant.[84]

Treatment of cutaneous melanoma is primarily surgical and is similar in both pregnant and nonpregnant patients. Early diagnosis and thickness of the lesion are predictors of therapeutic prognosis.[4] Lesions 1 mm or less in thickness should be excised with a 1 cm margin; intermediate lesions (1–4 mm thickness) should be excised with a 2 cm margin and lesions that warrant lymph node dissection, should be operated under GA, preferably in the second trimester.[85]

Staging of melanoma in a pregnant woman has enormous importance, as less thick lesions can be excised under local anesthesia. Biopsy of sentinel lymph node during gestation is subjected to a debate among various authors, as some advocate for delay until the postpartum period in view of risk to the fetus,[86] whereas the majority recommend that sentinel lymph node biopsy can be conducted anytime after the 1st trimester to avoid complications during organogenesis.[8387,88]

Basocellular carcinoma (if not growing) in the thorax or abdomen can be removed after delivery whereas an aggressive SCC on the nose may require urgent micrographic surgery.[10]

Vascular tumors: Hormonal status in pregnancy has a stimulant effect on vascular structures, which may cause growth in pyogenic granulomas, glomus tumors, and hemangioendotheliomas.[35] Pyogenic granulomas can be very symptomatic in a pregnant woman and necessitate treatment through shave removal with cauterization of the feeder's vessel. Lasers such as nonablative Nd:YAG and PDL can also be used according to few reports.[436]

Therefore, when a suspicious lesion is detected which shows signs of malignancy such as bleeding, change in size, and pigmentation, most dermatologists prefer a biopsy followed by necessary intervention such as an excision. The risk of leaving such a lesion untouched is greater than that of conducting a procedure for its removal.[2]

Vitiligo surgery

The course of vitiligo during pregnancy is variable and unpredictable and hence surgery is not recommended.

Hair transplantation

Generally, hair loss tends to improve during pregnancy. This, the cosmetic nature of the surgery and the prolonged duration of surgery necessitates any consideration of HT only after pregnancy.

Liposuction and fat grafting

Since the fetus places increased nutritional demand on the mother, liposuction and fat grafting may compromise the fetus’ nutritional requirements. Risk of fat embolism and occlusion also cannot be ruled out. Therefore, fat transfer surgery is not recommended during pregnancy and it is advised that the woman waits until her weight stabilizes after delivery.[25]

Suturing and suture removal

Due to delayed cicatrization in pregnant women, it is advised to use longer lasting absorbable sutures or nonabsorbable sutures with high tensile strength, especially over the trunk and abdomen. They should be left 5–7 days longer than usual.[1] Also, removal of sutures should be in stages to prevent any chances of dehiscence.[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.