What causes hyperpigmentation during pregnancy?
The placenta is an endocrine organ and it releases hormones such as estrogen and progesterone. This has wide-ranging effects throughout your body, including your skin. Estrogen stimulates the cells that produce melanin — called melanocytes — and progesterone augments this effect (Sumit 2012).
Even when not pregnant, the menstrual cycle and oral contraceptives can also cause melasma due to these hormonal interactions with melanocytes (Sheth and Pandya 2011).
Pregnancy is a time when a large majority — around 90% — of women notice some changes in their skin. The most common are hyperpigmentation and stretch marks. Changes in hair are also common, and may include hirsutism (excessive hair growth on the face, chest, and back). Some of you may notice a lusher mane during pregnancy. Fortunately or unfortunately, the extra hair on your face and head will also fall out after pregnancy, and the prolonged shedding may last for several months or more than one year postpartum (Tunzi 2007).
Your nails will grow faster during pregnancy but this also resolves postpartum. Vascular changes from estrogen can cause spider veins, reddened palms, and varicose veins — but again these usually regress postpartum (Tunzi 2007).
As for hyperpigmentation specifically, it may be termed melasma — older terms include chloasma or "mask of pregnancy." Melasma often resolves on its own postpartum, but in many cases it lasts for years beyond pregnancy (Sheth and Pandya 2011).
For so many skincare ingredients, there is just not that much data about safety during pregnancy — and even less data about breastfeeding. People are reluctant to run tests on pregnant women, and rightly so. The drawback is that we're making choices with limited data, so it's generally advised to err on the side of caution. Always consult a dermatologist or OB/Gyn before adding anything new to your routine or if you feel unsure about any existing products you're using.
Sunscreen can help prevent melasma
Although your melasma is hormonally driven during pregnancy and may develop even without sun exposure, you should use sunscreen regularly.
A study by Lakhdar and colleagues in 2007 found that daily use of broad-spectrum sunscreen in pregnant women reduced the rate of new melasma cases by more than ten times. Without sunscreen, the probability of melasma in pregnancy was observed to be around 53%. With sunscreen, it drops drastically to 2.7%.
We cannot stress this enough: the best cure for hyperpigmentation is to prevent it in the first place. Wear sunscreen.
You might have heard that chemical sunscreens should be avoided because oxybenzone can make it into your systemic circulation (Dinardo and Downs 2019). This is why some dermatologists will tell you that if you wish to err on the side of caution, you can avoid chemical sunscreens and use a mineral sunscreen containing zinc or titanium dioxide.
Mineral sunscreens are basically ground-up rocks, and they're not absorbable into the skin (Putra et al 2022). The drawback is that they tend to be more sticky and can leave residue on the skin unless you rub it in well. But I think the benefits far outweigh the inconvenience — and nowadays there are plenty of great mineral sunscreens on the market to choose from.
Vitamin C (Ascorbic Acid) — Fine to use
Vitamin C, also known as Ascorbic Acid, is both an antioxidant and a tyrosinase inhibitor that can help reduce hyperpigmentation.
A tyrosinase inhibitor is a substance that helps to block the action of an enzyme called tyrosinase. Tyrosinase plays a key role in the production of melanin — the pigment responsible for the color of our skin, hair, and eyes. By inhibiting tyrosinase, these substances can help reduce melanin production, which is helpful in treating hyperpigmentation and dark spots.
Oral Vitamin C has been found to be safe to take during pregnancy with no evidence of harm to the fetus. It has also been rated Category A in pregnancy by the FDA — meaning it has been evaluated by clinical trials in pregnant women and deemed safe. With Vitamin C, you can be confident that it is safe to use during pregnancy (Rumbold et al. 2015).
By the way, we go more in depth about FDA ratings for pregnancy safety in our Acne and Pregnancy video. Click here for our Acne and Pregnancy video.
Azelaic Acid — Fine to use
Azelaic acid is another tyrosinase inhibitor like Vitamin C — and it's probably the ingredient that dermatologists recommend most for treating melasma in pregnant women.
Azelaic acid is considered safe to use during pregnancy. It's a normal constituent of milk, and it's also found in wheat, rye, and barley — so it's something people ingest all the time, just like Vitamin C. Azelaic acid is rated Category B by the FDA, which means it is considered safe based on animal studies showing no fetal effects. There are no studies of azelaic acid in pregnant human women, but that's the case for most ingredients. In general, Category B ingredients are also deemed safe to use during pregnancy.
Azelaic acid may not be the most potent tyrosinase inhibitor, but due to its favorable safety profile it can be offered at high concentrations — 10% OTC and up to 20% by prescription. At 20%, azelaic acid performs comparably to 4% hydroquinone (Balina and Graupe 1991). Arbutin and kojic acid are more potent tyrosinase inhibitors, but if you're pregnant or nursing, azelaic acid might be the better option — more on why below.
Azelaic acid is also anti-microbial, so you might see it featured in anti-acne products. If you're pregnant and dealing with multiple skin concerns, azelaic acid is a great all-around ingredient.
Hydroquinone — Definitely do not use
In terms of treating hyperpigmentation, hydroquinone is considered a highly effective treatment option. However, it has many downsides — including being considered unsafe and toxic by the Cosmetic Ingredient Review (CIR) due to the risks of exogenous ochronosis, skin bleaching, and toxicity to melanocytes. Hydroquinone is banned in Europe and now available only by prescription in the US.
When it comes to pregnancy, there are additional concerns. Hydroquinone is very good at penetrating the skin and entering the bloodstream. It's estimated that 35–45% of topically applied hydroquinone can reach your bloodstream (Bozzo et al. 2011, Murase et al. 2014). This is an enormous amount — most skincare ingredients do not reach your bloodstream at all.
This high level of absorption is one of the reasons hydroquinone is not recommended during pregnancy. Why risk absorbing a substance considered toxic when you have other safe alternatives? Hydroquinone is often combined with a corticosteroid, which must also be taken with caution during pregnancy as corticosteroids can stunt fetal growth.
Retinoids — Definitely do not use
Retinoids are a true do-it-all ingredient — the first mentioned for anti-aging and acne, and one of the top ingredients used to treat hyperpigmentation. But retinoids — both oral and topical — are considered unsafe to use while pregnant due to the risk of birth defects.
Retinoids are Vitamin A derivatives, and Vitamin A is crucial for many functions including proper fetal development. The problem lies in the high amounts of Vitamin A that enter your blood circulation when you take retinoids. These high amounts lead to birth defects in the developing fetus — something called retinoid embryopathy. When Accutane (an oral retinoid) was first introduced in 1982, there were hundreds of reported birth defects as a result (AAD).
Topical retinoids are much less likely to reach your bloodstream than oral retinoids, and clinical studies suggest that topical retinoids like tretinoin do not raise overall serum Vitamin A levels nor lead to retinoid embryopathy. However, there are reported cases and anecdotal evidence associating topical retinoid use with birth defects in rare instances (Bozzo 2011, Murase et al. 2014).
It's just not worth it. Considering there are other options to treat hyperpigmentation, retinoids during pregnancy are a hard no.
Arbutin — Maybe
Arbutin is a compound derived from the bearberry plant and a great hyperpigmentation fighter — a tyrosinase inhibitor. There are two types considered safe by the CIR: alpha and beta arbutin. Alpha arbutin is the form commonly found in skincare products and is a derivative of hydroquinone — though unlike hydroquinone, it is considered safe to use by the CIR.
The concern over arbutin is based on studies showing that skin bacteria and UV can lead to hydrolysis of alpha arbutin into hydroquinone, although this amount is believed to be small (Boo 2021, Garcia-Jiminez et al. 2017). Due to this association with hydroquinone, some dermatologists recommend pregnant women avoid arbutin, while others say it is safe to use.
At Maelove, we recommend that you first speak with your doctor about this ingredient to get their opinion. Personally, as a pregnant woman myself, I have been using this ingredient in our Fade Away brightening serum. But do what feels comfortable for you and consult your doctor with any concerns.
Tranexamic Acid (TXA) — Maybe
Tranexamic Acid has a unique pathway to prevent melanin production (Sheth and Pandya 2011b). Its mechanism blocks both UV-induced and pregnancy/hormonally induced hyperpigmentation (Maeda and Tomita, 2007; see figure from Atefi et al. 2017).
In a direct matchup against hydroquinone, a clinical trial showed 5% TXA was as effective as 2% hydroquinone in reducing melasma spot area and intensity — but with less dryness, less irritation, and higher satisfaction levels (Atefi et al. 2017).
Given its unique mechanism of blocking pregnancy-related hyperpigmentation via inhibition of plasminogen activator and plasmin, it is ideal for hormonal melasma. Oral TXA is already used in pregnant women to prevent hemorrhage, as TXA is also involved in blood clotting. Topical TXA is rated Category B by the FDA, which means it is generally considered safe.
Because high concentrations of TXA can cause blood clotting, some dermatologists and OB/Gyns may have differing recommendations on whether to use TXA during pregnancy — even though the concentrations used to treat hyperpigmentation are much lower than those used to prevent hemorrhage. At Maelove, we feel it would be a good idea to speak to both your dermatologist and OB/Gyn if you're interested in using tranexamic acid.
Kojic Acid — Maybe
Kojic acid doesn't seem to reach the bloodstream in substance, so it has what medical professionals would call low systemic absorption — which is good for pregnancy. Animal studies have also shown no risk to fetal development.
However, there have been no human studies, and the FDA has no rating on kojic acid. For this reason, some doctors would err on the side of caution and not recommend it during pregnancy, while others would say it's fine.
At Maelove, we recommend that you first speak with your doctor about this ingredient to get their opinion. Personally, as a pregnant woman myself, I have been using this ingredient in our Fade Away brightening serum. But do what feels comfortable for you and consult your doctor with any concerns.
Laser and Light Therapy — Maybe
Resurfacing with fractionated laser is FDA approved to treat melasma. Intense Pulsed Light (IPL) therapy has also shown promise. With these laser therapies, there are risks of post-inflammatory hyperpigmentation, which could potentially worsen the problem. Because of this, laser and light therapies are usually recommended only after topical treatments have failed (Sheth and Pandya 2011b).
While laser and light therapies are generally regarded as safe to use during pregnancy, the numbing solution could affect the developing fetus. Consult a dermatologist before getting a laser treatment (Pugasheti 2013).
Recap
To summarize, here's a quick reference for each ingredient and its pregnancy safety status:
- Sumit (2012). Estrogen, progesterone, and melanocyte stimulation in pregnancy-related hyperpigmentation.
- Sheth VM, Pandya AG (2011). Melasma: a comprehensive update part I. Journal of the American Academy of Dermatology.
- Sheth VM, Pandya AG (2011b). Melasma: a comprehensive update part II. Journal of the American Academy of Dermatology.
- Tunzi M (2007). Common skin conditions during pregnancy. American Family Physician.
- Lakhdar H et al. (2007). Effectiveness of broad-spectrum sunscreen in the prevention of chloasma in pregnant women. Journal of the European Academy of Dermatology and Venereology.
- Dinardo JC, Downs CA (2019). Dermatological and environmental toxicological impact of the sunscreen ingredient oxybenzone/benzophenone-3. Journal of Cosmetic Dermatology.
- Putra IB et al. (2022). Review of sunscreen and photoprotection in pregnancy.
- Rumbold A et al. (2015). Vitamin C supplementation in pregnancy. Cochrane Database of Systematic Reviews.
- Balina LM, Graupe K (1991). The treatment of melasma. 20% azelaic acid versus 4% hydroquinone cream. International Journal of Dermatology.
- Bozzo P et al. (2011). Safety of skin care products during pregnancy. Canadian Family Physician.
- Murase JE et al. (2014). Safety of dermatologic medications in pregnancy and lactation. Journal of the American Academy of Dermatology.
- Boo YC (2021). Ascorbic acid (vitamin C) as a cosmetic ingredient. Antioxidants.
- Garcia-Jiminez A et al. (2017). Skin-microbiota-mediated arbutin biotransformation and implications for hyperpigmentation.
- Maeda K, Tomita Y (2007). Mechanism of the inhibitory effect of tranexamic acid on melanogenesis in cultured human melanocytes. Journal of Health Science.
- Atefi N et al. (2017). Efficacy of tranexamic acid versus hydroquinone in treatment of melasma. Journal of Research in Medical Sciences.
- Pugasheti R et al. (2013). Laser therapy for pregnancy-related dermatoses. Dermatologic Therapy.
- American Academy of Dermatology (AAD). Isotretinoin (Accutane) and birth defects.
