Topical Medications in Pregnancy and Lactation

Acne Medications

Consider:

• Azelaic acid (minimal data; no known fetal effects; skin absorption 4% to 8%; ACOG-recommended)^8,20
• Benzoyl peroxide (low systemic absorption [5%]; ACOG-recommended)^8,20
• Clindamycin (low systemic absorption; no known association between topical use and malformations)^5,8,21
• Erythromycin (low systemic absorption; most data do not suggest risk with systemic use)^5,21
• Salicylic acid (amount absorbed less than with low-dose aspirin, which does not increase malformations or pregnancy complications; ACOG-recommended)^20,21

Avoid:

• Retinoids (tretinoin, adapalene, tazarotene, “cosmeceutical” retinoids) (case reports of retinoid-like teratogenic effects with tretinoin; case report of ocular malformation with adapalene; tazarotene contraindicated [teratogenic in rats and rabbits]).^5,22 Check pregnancy test within two weeks before starting tazarotene, and start during normal menstrual cycle.⁵
• Dapsone (better-studied options are preferred)²¹

Consider:

• Azelaic acid (low systemic absorption [4% to 8%]; present in milk, wheat, rye, and barley naturally)⁸
• Benzoyl peroxide (low systemic absorption [5%])^6,8
• Clindamycin (infant side effects unlikely; breast application could cause diarrhea)⁶
• Erythromycin (infant side effects unlikely; breast application could cause diarrhea)⁶
• Salicylic acid (unlikely to be significantly absorbed)⁶
• Retinoids (tretinoin, adapalene, tazarotene) (tretinoin and adapalene poorly absorbed, but limit use of adapalene and tazarotene [e.g., apply tazarotene to no more than 20% of body surface area]).⁶

Avoid:

• Dapsone (case of hemolytic anemia in breastfed infant of mother taking oral dapsone; alternatives preferred).^5,6

Analgesics

Consider:

• Lidocaine (Lidoderm) (systemic use compatible; low systemic absorption)^2,5

Avoid:

• NSAIDs (constriction of ductus arteriosus reported with diclofenac)^3,4
• Salicylates (teratogenic effects and constriction of ductus arteriosus reported with methyl salicylate)⁴

Consider:

• Diclofenac (low or undetectable levels in breast milk with systemic maternal use)⁶
• Lidocaine (Lidoderm) (low levels in breast milk with systemic maternal administration; ingested lidocaine poorly absorbed by infant)⁶

Avoid: Salicylates (no data)

Anesthetics

Consider:

• Lidocaine (systemic use compatible)⁵
• Dibucaine (systemic levels likely minimal)¹³
• Pramoxine (not thought to be absorbed)⁵
• Prilocaine (no fetal harm in rats)¹³
• Benzocaine (absorption poor from intact skin, but avoid on mucous membranes or damaged skin due to paucity of data)⁵

Consider:

• Pramoxine (not thought to be absorbed)⁵
• Dibucaine (systemic levels likely minimal; unlikely to affect infant)^6,13
• Lidocaine (Lidoderm) (low levels in breast milk with systemic maternal administration; ingested lidocaine poorly absorbed by infant)⁶
• Prilocaine (low excretion of anesthetics into breast milk)⁶
• Benzocaine (absorption poor from intact skin, but avoid or limit use on mucous membranes or damaged skin)⁵

Note: Avoid direct ingestion by infant.^6,17

Antibiotics

Consider:

• Bacitracin (data limited, but no association with malformations)⁵
• Clindamycin, topical (low systemic absorption; conflicting first trimester data)^5,21
• Clindamycin, vaginal (per CDC, newer data demonstrate safety).¹⁴
• Erythromycin, (low systemic absorption; most data do not suggest risk with systemic use)^5,21 
• Metronidazole, topical (plasma level ~1% of peak level after a 250 mg oral dose)⁶
• Metronidazole, vaginal for bacterial vaginosis (most data do not suggest significant risk).⁵
• Mupirocin (low systemic absorption [<1%]; no fetal harm in rats or rabbits; quickly metabolized and eliminated)^5,6
• Neomycin (no association with malformations; risk of deafness not investigated, but expected to be small even with systemic maternal use)⁵
• Polymyxin (no association with malformations)⁵

Avoid:

• Metronidazole, vaginal for trichomoniasis (ineffective).^14,15

Consider:

• Bacitracin (poor systemic absorption)⁶
• Clindamycin, topical (low systemic absorption); unlikely to cause infant side effects^6,21 
• Clindamycin, vaginal (30% absorbed, but unlikely to cause infant side effects⁶ )
• Erythromycin (low systemic absorption; infant side effects unlikely)^6,21
• Metronidazole (neither topical nor vaginal have been studied during breastfeeding. After vaginal administration, plasma levels are <2% of those after a 500 mg oral dose. After topical administration, blood levels are about 1% of the peak plasma levels after a 250 mg oral dose.)⁶
• Mupirocin (low systemic absorption [<1%]; quickly metabolized and eliminated)^5,6
• Neomycin (clinically insignificant amounts expected in breast milk)⁶
• Polymyxin (poor systemic absorption)⁶

Antifungals (topical, intravaginal)

Note: a seven-day treatment course with a topical azole is recommended for vulvovaginal candidiasis during pregnancy.¹⁴

Consider:

• Nystatin (topical antifungal of choice; no association with malformations; poorly absorbed from intact skin and mucosal membranes)^5,8
• Ciclopirox (minimal systemic absorption [1.3% with occlusion]; not teratogenic in animals)^5,9
• Clotrimazole (minimal absorption from skin and vagina; no association with malformations, but some evidence suggests vaginal use in the first trimester may be associated with pregnancy loss.)⁵ See note.
• Miconazole (small amounts absorbed from vagina; no association with malformations, but vaginal use in first trimester associated with pregnancy loss.)⁵ See note.
• Selenium disulfide/sulfide (limited data; short-term use acceptable)⁸
• Terbinafine (minimal systemic absorption [<5%]; human data lacking, but not teratogenic in rats or rabbits; not a preferred option.)^5,8

Consider:

• Nystatin (an antifungal of choice; has the most data; poor absorption from intact skin and mucosal surfaces)^5,6,8
• Ciclopirox (minimal systemic absorption [1.3% with occlusion; likely safe])^5,6,9
• Clotrimazole (an antifungal of choice; has the most data; poor absorption from skin and vagina; likely safe)^5,6,8,9
• Miconazole (no data; poor absorption from skin and vagina; no risk expected)^5,6
• Selenium disulfide (a single case report of lactation suppression)^8,9
• Terbinafine (systemic absorption <5%; likely safe)^5,6,9

Antivirals

Consider:

• Acyclovir (not associated with malformations)⁵

Avoid:

• Imiquimod (limited human data)⁵

Consider:

• Acyclovir (even with the highest maternal systemic doses, the amount in breast milk is only about 1% of the typical infant dose)⁶
• Imiquimod (poor systemic absorption; amount in breast milk probably clinically insignificant)^5,6

Corticosteroids (ointments and creams)

Consider:

• Low- to mid-potency agent (e.g., hydrocortisone) (not associated with malformations)⁸

Avoid:

• High-potency agents (e.g., clobetasol) (possible association with low birth weight)^8,10

See our chart, Comparison of Topical Corticosteroids, for help identifying low, medium, or high-potency agents (US) (Canada).

Consider:

• Any (minimal risk of infant exposure, but prudent to use least potent agent necessary on smallest area necessary)^6,9

Avoid:

• High-potency agent on nipples (case report of hypertension in infant)^9,10

Hemorrhoid Products

Consider (for external application only¹⁹):

• Anesthetics (see above)
• Hydrocortisone²³ (see “Corticosteroids, above, for details)
• Witch hazel^16,23

Avoid:

• Phenylephrine (may reduce uterine blood flow;risk of minor malformations, inguinal hernia, and clubfoot with 1^st trimester use of nasal spray)^5,23

Consider:

• Hydrocortisone (rectal cream or suppository poses very little risk to infant)⁶
• Pramoxine (thought not to be absorbed)⁵
• Phenylephrine (no human data; probably compatible, but could theoretically reduce milk supply)^5,6
• Witch hazel (insufficient evidence, but recommended in pregnancy)^16,23,24

Lice and Scabies Treatments

Consider:

• Permethrin (≤2% absorbed; neither animal nor limited human data suggest risk to embryo or fetus; a preferred option for scabies or lice)^5.8
• Pyrethrins with piperonyl butoxide (poor absorption; a preferred option for lice)^5,8
• Crotamiton (<1% absorbed; considered safe)⁸
• Ivermectin (no data for topical product; systemic administration teratogenic in animals at maternally toxic dose, but no evidence of teratogenicity in humans)⁵
• Spinosad (Natroba [US]) (spinosad not systemically absorbed; also contains benzyl alcohol, but significant embryo/fetal exposure unlikely)⁵
• Malathion (<10% absorbed; not teratogenic in rats or rabbits)¹⁸

Note: CDC guidelines recommend permethrin or pyrethrin/piperonyl butoxide for public lice, and permethrin for scabies, in pregnant women.¹⁴

Consider:

• Permethrin (minimal absorption [≤2%]; rapid metabolism; used in infants)^5,6
• Pyrethrins with piperonyl butoxide (poorly absorbed)⁵
• Crotamiton (<1% absorbed; minimal data; likely safe)⁸
• Ivermectin; no data for topical product, but poorly excreted into breast milk after oral administration)⁶
• Spinosad (Natroba [US]) (spinosad not systemically absorbed; also contains benzyl alcohol, but significant infant exposure unlikely)⁵

Avoid:

• Malathion (<10% absorbed; limited data; may cause respiratory depression)^6,9

Note: CDC guidelines recommend permethrin or pyrethrin/piperonyl butoxide for public lice, or permethrin for scabies, in lactation.¹⁴

Nasal Sprays (cold, allergy)

Consider:

• Saline nasal spray¹²
• Beclomethasone (no association with malformations)^5,11
• Budesonide (extensive human safety data; ~20% absorbed; agent of choice)^5,7,11,12
• Ciclesonide (no human data; likely only minimal amounts cross the placenta)^5,11
• Flunisolide (limited human data (inhaled route); 50% of dose reaches systemic circulation, and amount reaching embryo/fetus may be even less)⁵
• Fluticasone (no risk identified with inhaled or nasal use; significant embryo/fetal exposure unlikely; considered safe)^5,11,12
• Mometasone (no human data; systemic absorption virtually undetectable; considered safe)^5.11

Avoid:

• Phenylephrine (risk of minor malformations, inguinal hernia, and clubfoot with 1^st trimester use; could reduce uterine blood flow)⁵
• Oxymetazoline (potential risk of renal malformations with 2^nd trimester use, and pyloric stenosis with 1^st trimester use; could reduce uterine blood flow)^1,5
• Triamcinolone (association with respiratory tract defects)^5,11
• Xylometazoline (risk of pyloric stenosis with 1^st trimester use; could reduce uterine blood flow)^1,5

Consider:

• Saline nasal spray¹²
• Corticosteroid nasal sprays (amounts in breast milk probably too small to cause harm)⁶
• Phenylephrine (less likely to reduce milk production than oral agent)⁶
• Oxymetazoline (little expected to reach infant. Recommended over oral decongestants.)⁶

Psoriasis Medications

Consider:

• Moisturizer (considered safe)¹⁰
• Low- to mid-potency topical corticosteroid (e.g., hydrocortisone) (not associated with malformations)^8,10

Avoid:

• High-potency corticosteroid (e.g., clobetasol) (possible association with low birth weight)^8,10
• Calcipotriene/calcipotriol (fetal skeletal abnormalities in animals; could use small amount if no alternative)^8,10
• Calcineurin inhibitors (tacrolimus, pimecrolimus; little topical safety data available; oral tacrolimus associated with prematurity and low birth weight)^8,10
• Coal tar (mutagenic/carcinogenic)⁸

See our chart, Comparison of Topical Corticosteroids, for help identifying low, medium, or high-potency agents (US) (Canada).

Consider:  

• Moisturizer (considered safe)¹⁰
• Corticosteroids, any (minimal risk of infant exposure, but prudent to use least potent agent necessary on smallest area necessary)^6,9
• Tacrolimus (low systemic absorption)^5,6
• Pimecrolimus (low systemic absorption; high plasma protein binding [i.e., minimal passage into breast milk])^5,6
• Calcipotriene/calcipotriol (poor systemic absorption; vitamin D analogue; probably low risk)^5,6

Avoid:

• Coal tar (mutagenic/carcinogenic; if absolutely needed, use on smallest area possible)⁶