Safety of Cosmetic Dermatologic Procedures During Pregnancy

Analysis of Breast Milk Samples in Lactating Women After Undergoing Botulinum Toxin Injections for Facial Rejuvenation: A Pilot Study

Abstract Background: There are little data on the risk to a breastfeeding infant after facial botulinum toxin injections to the mother. Objective: To detect the presence of botulinum toxin in breast milk from lactating subjects treated with facial botulinum toxin injections, as measured by enzyme-linked immunosorbent assay (ELISA). Methods: For this pilot study, lactating women were injected with standardized facial botulinum toxin type A (BTXA) (range 40-92 U). Collected breast milk samples over 5 days were analyzed for the presence of botulinum toxin. Exclusion criteria included (1) lactating women still using their breast milk for their infant, (2) muscular disorders, (3) any medication that could interfere with neuromuscular function, (4) uncontrolled systemic disease, (5) pregnant, and (6) neuromodulator injection in the past 90 days. Results: Four lactating women were recruited. Eight samples had no BTXA detected, whereas 8 of the 16 total had detectible amounts, which were well below the reported lethal oral dose for an infant. Conclusion: Although the exclusion of lactating women from receiving cosmetic botulinum toxin injections is out of an abundance of caution to the theoretical risk to the infant, this study helps support the notion that facial botulinum toxin injections do not warrant an interruption in breastfeeding. Further studies with larger sample sizes are needed.

Update on Chemical Peels

Chemical peeling is a procedure used for cosmetic improvement of the skin or treatment of some medical skin disorders, by the application of chemical exfoliant. In spite of a long history of clinical use of chemical peels, understanding of the science behind the procedure is still evolving. In this article, we review new concepts, understandings, and publications in the field of chemical peels.

Otolaryngology and the Pregnant Patient

Importance

Pregnancy may result in physiologic and pathologic changes in the head and neck. Otolaryngologists may need to intervene medically or surgically with pregnant patients. Careful consideration of risks to both the gravid patient and the developing fetus is vital.

Observations

Patients may present with otolaryngologic complaints exacerbated by or simply occurring during their pregnancy. Symptoms of hearing loss, vertigo, rhinitis or rhinosinusitis, epistaxis, obstructive sleep apnea, sialorrhea, voice changes, reflux, subglottic stenosis, and benign and malignant tumors of the head and neck may prompt evaluation. While conservative measures are often best, there are medications that are safe for use during pregnancy. When required, surgery for the gravid patient requires a multidisciplinary approach.

Conclusions and Relevance

Otolaryngologic manifestations in pregnant patients may be managed safely with conservative treatment, medication, and surgery when necessary. Treatment should include consideration of both the pregnant patient and the developing fetus.

Reproduction, skin aging, and sleep in middle-aged women

There is a growing trend for women to delay having children, with a significant number of women postponing motherhood until the third or fourth decade of life. At the same time, these middle-aged women may be more concerned about skin aging and use dermatologic procedures to delay or repair the effects of aging, environmental factors, and oxidative stress on the skin. It has been suggested that the use of skin cosmetics and procedures may play a role in the reproductive system, although their possible effects have not yet been clearly elucidated. Another crucial factor that needs to be raised in this context is poor sleep, which seems to have an important relationship with both reduced fertility and accelerated skin aging, especially when it is associated with greater oxidative stress and hormonal imbalance. This review discusses the important triad of sleep, dermatology, and reproduction, a subject that has received relatively little attention; and, given its potentially wide-ranging implications, one that deserves more frequent and detailed consideration in future studies. Understanding this complex web of interactions could help to provide outcomes that include healthier skin, safety, improved self-esteem, and successful fertility treatments, all of which can directly affect quality of life.

Dermatologic and cosmetic procedures in pregnancy

Background:

Materials and Methods:

Results:

Vulval lymphangiectasia in pregnancy-a rare case report

Difficulty in arriving at a diagnosis of vulval lesions of women presenting in labor leads to a dilemma in deciding the delivery route. Here we present a case of large vulval lesion extending from mons pubis to anterior half of perineum presenting in labor in a 27-year-old second gravida with term pregnancy. History revealed an onset of vulval swelling within 3 months of starting antituberculosis treatment for cervical tuberculous lymphadenopathy at the age of 25 years. There was no associated inguinal lymphadenopathy or edema of the legs. Cesarean section was performed, anticipating difficulty in suturing the perineal tear with vaginal delivery. Biopsy revealed a diagnosis of vulval lymphangiectasia. Though various treatment modalities are available, complete resolution of the lesion remains a challenge. Awareness among healthcare workers and early diagnosis and intervention could avoid the extension of the lesion and its sequel in labor.

Intended Human Exposure to Non-ionizing Radiation for Cosmetic Purposes

Cosmetic devices using non-ionizing radiation (NIR) are increasingly available for people who wish to modify their appearance for aesthetic purposes. There are a wide range of NIR modalities used for cosmetic procedures, including devices that use optical radiation (laser, intense pulsed light, and light-emitting diode), electromagnetic fields, and ultrasound. Common procedures involving the application of NIR include epilation, skin rejuvenation, body sculpting and contouring, treatment of vascular and skin lesions, tattoo removal, and scar reduction. The majority of research on the use of NIR cosmetic devices has focused on the efficacy of the treatment rather than adverse effects or complications. Studies that assessed safety consisted mostly of case reports and small case series. Common adverse effects on the skin reported include mild and transient pain, erythema, swelling, and changes in pigmentation. Less common, more severe side effects include burns, blisters, scarring, persisting erythema, altered pigmentation, and eye damage. Some of the latter may have resulted from treatment errors. Particular groups of people that may be at greater risk from optical radiation include people with dark skin, with high sun exposure, and taking photosensitizing medications or supplements. There is lack of evidence for the safety profile of cosmetic NIR procedures during pregnancy. Reports of injuries to workers administering treatments with cosmetic NIR devices are rare, but inadvertent damage to the eye from optical devices may occur. Randomized controlled trials are required to fully assess potential adverse effects from the use of NIR cosmetic devices. Regulation varies worldwide and some regions apply the same safety classification and guidance as for medical devices. In order to reduce harm associated with the use of cosmetic devices, ICNIRP considers it important that regulations that cover all types and frequencies of cosmetic NIR devices are adopted worldwide and that there is greater oversight regarding their use.

Utilization of Laser Therapy During Pregnancy: A Systematic Review of the Maternal and Fetal Effects Reported From 1960 to 2017

BACKGROUND

Due to concerns regarding maternal and fetal safety and the absence of evidence to the contrary, laser treatment during pregnancy has traditionally been limited to situations of absolute necessity.

OBJECTIVE

This review seeks to examine the available evidence to determine the safety of laser therapy during pregnancy.

METHODS

Medical databases were searched for relevant reports from all specialties regarding the use of lasers during pregnancy from 1960 to 2017. A legal case review was also performed.

RESULTS

Twenty-two publications in the literature reported the use of various laser wavelengths in 380 pregnant women during all trimesters. Other than 1 case of premature rupture of membranes questionably related to the laser treatment, there were no cases of maternal or fetal morbidity or mortality, premature labor, or identifiable fetal stress.

CONCLUSION

The available evidence, limited to low evidence level case reports and series, indicates cutaneous laser treatment during pregnancy is safe for both mother and fetus. Furthermore, laser physics and optics dictate there should theoretically be no risk of fetal laser exposure from commonly used cutaneous lasers.

Botulism During Pregnancy and the Postpartum Period: A Systematic Review

Background

Maternal and fetal outcomes associated with botulism and botulinum antitoxin use during pregnancy and the postpartum period have not been systematically reviewed.

Methods

We searched Global Health, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Medline databases from inception to May 2015 for studies published on botulism or botulinum antitoxin use during pregnancy and the postpartum period, as well as the Centers for Disease Control and Prevention National Botulism Surveillance database. Our search identified 4517 citations.

Results

Sixteen cases of botulism during pregnancy (11 in the third trimester) and 1 case during the postpartum period were identified. Ten cases were associated with confirmed or likely foodborne exposure; 2 cases were attributed to wound contamination related to heroin use, and the source of 5 cases was unknown. Eleven women with botulism had progressive neurologic deterioration and respiratory failure, requiring intensive care unit admission. Four women had adverse outcomes, including 2 deaths and 2 women who remained in a persistent vegetative state. No neonatal losses or cases of congenital botulism were reported. Among the 12 cases that reported neonatal data, 6 neonates were born preterm. No adverse maternal or neonatal events were identified as associated with botulinum antitoxin therapy among 11 patients who received it.

Conclusions

Our review of 17 cases of botulism in pregnant/postpartum women found that more than half required ventilator support, 2 women died, and 6 infants were born prematurely. A high level of clinical suspicion is key for early diagnosis and treatment of botulism. Care of pregnant women or new mothers with botulism can include preparation for possible intubation.

Cutaneous Surgery in Patients Who Are Pregnant or Breastfeeding

Dermatologic surgery in pregnant/postpartum patients requires deliberate consideration. Although surgery can be safely performed during any trimester, the second trimester and immediate postpartum period is optimal. Surgery should not be delayed for melanoma/high-risk skin cancers. Perioperative positioning, analgesic, antiseptic, and antibiotic selection should be deliberate to avoid risk to the patient/fetus/infant. The left lateral tilt position reduces aortocaval compression syndrome. Lidocaine and epinephrine can be used safely. Alcohol and chlorhexidine are considered safe. Antibiotics commonly used in skin surgery are safe in pregnancy and lactation. Acetaminophen is first line for pain management. Nonsteroidal antiinflammatory drugs should be avoided.

Chemical peels in the treatment of acne: patient selection and perspectives

Acne vulgaris is the most common skin disorder in adolescents and young adults. It carries a significant psychological and economic burden to patients and society. A wide range of therapeutic options are available, including topicals and systemic therapies. Chemical peeling is a skin resurfacing procedure intended to regenerate normal skin from the application of exfoliative agents. It has been used for the treatment of acne vulgaris and other skin disorders for decades. There are several chemical agents with variable mechanisms of action, usually classified as superficial, medium, and deep peels. When selecting the patient and the appropriate peel, the dermatologist individualizes therapy, and performs an extensive interview, including past medical history and physical exam. Several host factors can affect the outcome of this procedure, including current psychological state, medications, history of surgery, and immune system, among others. The physician must also be confident that the peel is safe and effective for the target patient. The Fitzpatrick skin type scale is a useful tool to classify patients based on skin color and ability to tan, but also can be used to evaluate preoperative risk of postpeel response and complications. Dark-skinned patients (Fitzpatrick skin type IV-VI), including blacks, Asian, and Hispanic/Latino, are at higher risk of postinflammatory/postpeel hyperpigmentation. When treating these populations, deep chemical peels should be avoided, and preoperative preparation emphasized. There are many studies available in the literature supporting the use of superficial to medium depth peels as adjuvant therapy for acne vulgaris. This review article aims to present the most important factors when selecting a patient for a chemical peel, the evidence behind its safety and efficacy, and special considerations when choosing a specific agent.

Development of A Machine Learning Algorithm to Classify Drugs Of Unknown Fetal Effect

Many drugs commonly prescribed during pregnancy lack a fetal safety recommendation - called FDA 'category C' drugs. This study aims to classify these drugs into harmful and safe categories using knowledge gained from chemoinformatics (i.e., pharmacological similarity with drugs of known fetal effect) and empirical data (i.e., derived from Electronic Health Records). Our fetal loss cohort contains 14,922 affected and 33,043 unaffected pregnancies and our congenital anomalies cohort contains 5,658 affected and 31,240 unaffected infants. We trained a random forest to classify drugs of unknown pregnancy class into harmful or safe categories, focusing on two distinct outcomes: fetal loss and congenital anomalies. Our models achieved an out-of-bag accuracy of 91% for fetal loss and 87% for congenital anomalies outperforming null models. Fifty-seven 'category C' medications were classified as harmful for fetal loss and eleven for congenital anomalies. This includes medications with documented harmful effects, including naproxen, ibuprofen and rubella live vaccine. We also identified several novel drugs, e.g., haloperidol, that increased the risk of fetal loss. Our approach provides important information on the harmfulness of 'category C' drugs. This is needed, as no FDA recommendation exists for these drugs' fetal safety.

A review of the safety of cosmetic procedures during pregnancy and lactation

The safety of cosmetic procedures in patients who are pregnant and/or lactating is a complex clinical question surrounded by uncertainty. Our objective is to consolidate data on the safety of commonly requested cosmetic procedures during pregnancy and lactation after a systematic review of the current literature to guide evidence-based care in the future. A systematic search of the PubMed database was conducted for articles on cosmetic procedures during pregnancy and lactation. Due to a lack of controlled trials, case reports and series were considered. Minor procedures such as shave, punch, snipping, and electrocautery are considered safe. With respect to chemical peels, glycolic and lactic acid peels are deemed safe; however, trichloracetic and salicylic acid peels should be avoided or used with caution. Although safety data on botulinum toxin A is insufficient, the procedure may be safe because systemic absorption and placental transfer are negligible. Sclerotherapy can be safe during pregnancy but must be avoided during the first trimester and after week 36 of the pregnancy. Laser and light therapies have been considered generally safe for patients with granulomatous conditions and condylomata. Epilation should be limited to waxing, shaving, and topical treatments instead of permanent procedures. In patients who are lactating, most therapies discussed above are safe but fat transfer, sclerotherapy, and tumescent liposuction are not recommended. Better evidence is needed to make concrete recommendations on the safety of cosmetic therapy during pregnancy and lactation but preliminary evidence suggests excellent safety profiles for many commonly requested cosmetic procedures.