Pharmacology and toxicology
Tacrolimus and pimecrolimus are used as local treatment for neurodermatitis. Although there arc no studies regarding topical use, these exist for systemic use of tacrolimus in transplant medicine (see Chapter 2.12).
The results do not indicate a risk of developmental disorders, Obviously, serum levels after local treatment with tacrolimus are much lower than in transplant patients. Therefore, this substance can be used topically when there are no acceptable alternatives. There are no data related to pimecrolimus.
Recommendation. When no alternatives exist, topical use on small surfaces is permissible. The use of pimecrolimus is not advised, but if it is used then no invasive prenatal diagnostics are indicated and certainly there is no reason for termination of pregnancy.
Salicylate and carbamide preparations
Keratolytics arc used to soften the keratin layer and for loosening scales. Salicylates are used as keratolytics in 2-10°/o solutions, or in 30-50% solutions in petroleum jelly for treatment of warts.
Carbamide preparations are used in 10% solutions. Systemic effects would not be expected, even in pregnancy, when used for the appropriate indications.
Recommendation. Topical use of the keratolytics mentioned above is no cause for concern with pregnant women when the medications are used on limited areas for limited periods of time.
Calcipotriol and dithranol
Calcipotriol is a vitamin D-, derivative. Generally, D-hypcrvitaminosis should be avoided during pregnancy. However, use in the recommended dosage range («lOOg/week of a 0.005% solution) does not lead to a disturbance in calcium homeostasis.
Systematic studies on prenatal toxicity in humans are lacking here, as they are with dithranol. As an antimitotic substance, it is theoretically suspect for pregnant women, though substantial absorption of the preparation (usually 1-3%) is not likely. There is no information on the topical use of the vitamin D derivative tacal-citrol during pregnancy. It is comparable to calcipotriol.
Recommendation. The above-mentioned substances should not be used over large areas, especially in the presence of inflammatory changes in the skin that make absorption more likely.
Selenium disulfide is used as a topical antifungal in the treatment of tinea vesicolor, as a topical keratolytic, and is applied topically to the scalp to control seborrheic dermatitis and dandruff. There are no systematic data implicating teratogenicity.
Recommendation. Local appllcation in small areas and for a limited period is acceptable.
Azelaic acid (nonanedioic acid) is an oxidation product of" oleic acid occurring in rancid fats. It has anti-inflammatory, antibacterial, and kcratolytic effects. It is also used in acne therapy. About 4-8°/o of the topically applied substance is absorbed systemically. Animal experiments have not shown teratogenicity (Akhavan 2003). Epidemiologic studies are lacking.
Recommendation. Azelaic acid is only to be used in pregnancy when absolutely necessary, on small skin surfaces, and preferably not during the first trimester. When used in pregnancy, there is no justification for invasive prenatal diagnostics or termination of pregnancy.
Sulfur (milk of sulfur) is present (at 2-10%) in lotions, creams, and powders, and is used as a mild keratolytic and bacteriostatic treatment. The bioavailability of topical sulfur is about 1% (Akhavan 2003). There are no data on its use during pregnancy.
Recommendation. When there is an indication for sulfur, it can be used on small skin areas in pregnancy. Systemic activity is unlikely.
Resorcin is an aromatic alcohol that is used in local acne therapy and in the treatment of other dermatoses as a bactericidal, fungicidal, keratolytic, exfoliative, and antipruritic agent, and for seborrheic dermatitis and psoriasis. It is also to be found in cosmetics and hair dye. There are no indications for teratogenicity. Systematic epi demiological research is lacking.
Recommendation. Topical treatment on a small area with resorcin, when indicated, is acceptable during pregnancy.
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