Good

Morning
 Cosmetics
in Pregnancy
Marijay M. Utulo, MD
Discussant

Nenita Lorenzo-Alberto, MD
Adviser

Ma. Angel Tan-Espiritu, MD

Moderator
 Objectives
 To enumerate the substances that
are present in selected cosmetic
products and elucidate their
possible teratogenic effects

 To provide an evidence-based
discussion on the use of common
cosmetic products and procedures
during pregnancy
 Case
• M.T.
• 19 years old
• G1P0
• Tondo, Manila
• Amenorrhea
 Past Medical History
• Unremarkable
 Family History
• Unremarkable
 Personal/Social/Sexual
History
• No vices
• FSC at 18 years old to a single,
non-promiscuous sexual
partner
• No history of OCP, IUD or STD
• Highschool graduate,
unemployed
 Menstrual History
• Menarche: 15 years old
• Regular monthly interval
• Duration: 3-5 days
• Amount: 3-4 pads per day
• No dysmenorrhea
• LMP: June 17, 2008
• PMP: May 2nd week 2008
• Amenorrhea: 19 weeks AOG
 Obstetric History
• G1 – 2008 present pregnancy
 Physical Examination
• BP 110/80mmHg PR 82bpm RR
20cpm T 37°C
• Wt 54kgs Ht 152cm BMI 23
• Pink palpebral conjunctivae,
anicteric sclerae
• Symmetrical chest expansion, no
retractions, clear breath sounds
• Adynamic precordium, normal rate,
regular rhythm
 Physical examination
• Soft flat abdomen, noted
hyperpigmented linea alba, corpus
enlarged and palpable at the level of
the umbilicus, no tenderness on
palpation
• Internal exam: Normal external
genitalia, smooth nulliparous vagina,
cervix smooth, soft, closed, corpus
enlarged to 18-20 weeks AOG, no
adnexal masses or tenderness
• No cyanosis or edema, full and equal
pulses
 Assessment
• Pregnancy Uterine 19 weeks
AOG, by LMP, NIL
• G1P0
• Plan:
– Serial Prenatal check
– Expectant management at term
 Problem
• Is there anything she can apply over
the hyperpigmented line below her
umbilicus?
• What about the stretch marks?
Ancient Egypt
 Ancient Egypt
• Malachite
• Galena
• Kohl
Greek Culture
• White Lead
• Red Lead
Physiologic Skin Changes
of Pregnancy
1. Hyperpigmentation
2. Striae gravidarum
3. Hair, Nail and Vascular Changes
 Hyperpigmentation
 Commonly affects:
Areolae
Axillae
Genitals
Scars
Nevi
 Greater sensitivity to hormonal
stimulation in anatomic regions with a
higher concentration of melanocytes
 Hyperpigmentation
Can be attributed to both
estrogen and progesterone

Other bioactive molecules in

the placenta can induce
pigmentation – human
placental lipids
 Hyperpigmentation
Chloasma (Mask of Pregnancy)
Most cosmetically troublesome
70% of pregnant women
Distribution:
centrofacial (63%)
malar (21%)
Mandibular (16%)
Melanin distribution:
epidermal
dermal
Malar Distribution
 Chloasma
Blotchy, irregularly shaped
patches of light- to dark-brown
hyperpigmentation with very
well demarcated borders
Resolves after pregnancy
May persist with recurrent
pregnancies
 Linea Nigra
• Linea alba – tendinous median
line on the anterior abdominal
wall also becomes
hyperpigmented
• Usually occurs during the first
trimester of pregnancy
 Striae Gravidarum
Commonly known as “stretch
marks”
Due to stretching of the
connective tissue of the skin
overlying the abdomen
Hormonal factors (increased
adrenocortical activity)
 Striae Gravidarum
Appear as pink or purple
longitudinal bands on the breast,
abdomen and thighs
Permanent, may only lighten and
be less visible postpartum
 Striae Gravidarum
No significant correlation was found
between skin type, socioeconomic
status, smoking, cream use, fetal
gender, or family history and the
risk of developing of striae
gravidarum
Women with a positive family history
of SG were more likely to develop
moderate/severe SG
Similar to previous studies, it was also
found that women who developed
SG were significantly younger and
had gained significantly more
weight during pregnancy
Osman et.al. (2007)
 Hair, Nail and Vascular
Changes
• Hair
– Prolongation of the anagen
phase – estrogen effect
– Enlargement of follicles in
dependent areas
• Mild hirsutism
• Thickening of scalp hair
• Hair
– Follicles in the anagen phase
rapidly enter catagen then telogen
face – hair shedding
– Telogen effluvium
• Nail changes
– increased brittleness
– transverse grooves
– onycholysis
– subungual keratosis
– faster nail growth
• Vascular changes – estrogen
effects
– dilation, instability, proliferation,
and congestion of blood vessels
– Spider telangiectasias (spider
nevi or spider angiomas)
• more common in light-complected
than dark-complected pregnant
women
• condition is most common during the
first and second trimesters.
• Vascular changes
– Palmar erythema
– In about 40% of women, saphenous,
vulvar, or hemorrhoidal varicosities
may occur.
– Vaginal erythema (Chadwick’s sign)
– Bluish discoloration of the cervix
(Goodell’s sign)
• Vasomotor instability
– facial flushing
– hot and cold sensations
– dermatographism
– worsening of pre-existing
Raynaud’s phenomenon
• Gingival hyperaemia and edema
– associated with gingivitis and bleeding,
especially in the third trimester
– Proliferation of capillaries within the
gums can give rise to the pyogenic
granuloma of pregnancy
• red or purple nodule on the gingiva
• no surgical intervention is necessary since it
will regress postpartum.
 Hyperpigmentation
• Glutathiones
• Mercury salts with
Corticosteroids
• Hydroquinone
• Sunscreens
 Glutathione
• Glutathione
– a compound composed of three
amino acids: glutamine, glycine,
and cysteine.
– It is primarily found in body cells.
The liver generates most of the
body's glutathione supply.
– naturally found in many food
sources.
 Glutathione
– The most well known role of
glutathione is as an antioxidant.
– an efficient scavenger of free
radicals and other reactive oxygen
species through enzymatic
reactions.
– an extra cellular antioxidant, and it
is also the main intracellular
antioxidant against protein, lipid or
enzymatic oxidation.
• Claims related to the skin were:
– whitening
– anti-aging
– skin rejuvenation
• All glutathione distributors claim that
their products had whitening effect
on the skin.
• Ninety-five percent (95.5%) had
antioxidant effects.
• Others claimed anti-aging effects by
ninety-one (91%).
• Based on animal and human studies, the
skin whitening effect of glutathione may
act by:
– Direct inactivation of the enzyme tyrosinase,
necessary in melanin (pigment) production
– Conversion of pigment to the lighter
phaeomelanin
– Quenching free radicals and peroxides that
contribute to tyrosinase activation and melanin
formation
– Modulation of depigmenting abilities of
melanocytotoxic agents
(Villarama and Maibach, 2005),
• Regarding the claim of anti-aging and skin
rejuvenation, no published reports were
found.
• As to its safety, no adverse effects were
found, but precautions were advised.
• It was reported that the IV glutathione had
adverse effects which include:
– Erratic blood sugar levels in diabetics
– Recurrence of arthritic pains
– Recurrence of hypothyroidism/hyperthyroidism
• The precautions of IV glutathione
(distributors' advice) are:
– Not for pregnant women
– Not for patients with acute liver
problems
– Patients must have eaten prior to
infusion
 Mercury salts with
Corticosteroids

• Bleaching products:
– Hydroquinone
– Highly potent corticosteroids
– Mercury salts

• There was a statistically significant

difference between highly potent
steroid users vs. non-users in terms
of placental and birth weights.
• However, there were no statistically
significant differences with respect to
blood pressure, weight, albuminuria,
occurrence of vaginal discharge,
gestational age at delivery, delivery
methods or complications, and Apgar
index of the newborn, among those who
used bleaching products vs. those who did
not, and among those who used highly
potent steroids vs. those who did not.
Mahe et. al. (2006)
• Mercury salts are no longer used as
whitening agents because of their
poisonous effects.
• Treatment of hyperpigmentation,
including melasma, is delayed until
6months postpartum to allow normal
recovery of the skin.
 Hydroquinone
 Structurally related to monobenzone
 Freely soluble in water and alcohol
 Topical application:
Inhibition of enzymatic oxidation of
tyrosine 3,4-dihydroxyphenylalanine
(dopa)
Suppression of other melanocyte
metabolic processes
 Hydroquinone

 Advised against its use during

pregnancy
 No studies regarding its use in
nursing mothers
 Pregnancy Category C
 Recommended once postpartum
 Sunscreens
• Consist of:
– zinc oxide
– talc
– titanium dioxide
• Form a physical barrier that
prevents solar radiation from
reaching the skin
 Sunscreens
• Should be used with bleaching
agents such as hydroquinone
once postpartum
• Can be used by pregnant
women with at least a sun
protection factor (SPF) of 35
 Striae Gravidarum
• No evidence that any specific
emollient and/or oil is effective
• Available products only
camouflage the stretch marks
 Striae Gravidarum
• Cochrane systematic review
– Trofolastin cream vs placebo
– Massage with Verum ointment vs
no treatment
– Both associated with less women
developing stretch marks
Young GL, Jewell D (1996)
 Striae Gravidarum
• Cochrane systematic review
– Conclusion:
• The active creams in the studies are
not widely available
• No particular ingredient was
specified
• No adverse effects were reported

Young GL, Jewell D (1996)

• Treatments for stretch marks
only camouflage the epidermal
layer of the skin
• No treatment is available since
the topical products cannot
reach the dermis where the
elastic layer of the skin is found
• Massage
– soothes stress
– improves circulation
– ease aches and pains
– Note: the therapist or person
doing the procedure should be
knowledgeable about pregnancy
body changes
 Hair, Nail, Vascular
Changes
• Hair Permming/Hair Dyeing
– Hair care products
• Include a variety of chemicals:
– Phenylenediamine
– toluene-diamine
– resorcinol
– aminozene
• Some of these compounds are
potentially mutagenic and
teratogenic
• Due to the limited studies done on
humans, it may be more prudent for
pregnant women to avoid hair
permanents and dyeing during the
first trimester
• However, it cannot be deduced that
all pregnant beauticians or those
who want to become pregnant,
resign from their work
• Hair Waxing
– No contraindication during
pregnancy as long as it’s been
routine for the patient
– Not recommended as a first time
procedure
• Nail treatments
– Manicure/Pedicure
• Safe to schedule during any
trimester
• Nail polish (soap, shampoo,
deodorants, fragrances, hair spray)
– Contain the chemical known as
phthalates
• Phthalates
– Phthalates are industrial chemicals
that can act as plasticizers, which
impart flexibility and resilience
– produce testicular injury, liver injury,
liver cancer, and teratogenicity in
rodent studies
– Some have anti-androgenic
properties
• Di-2-ethylhexyl phthalate (DEHP)
• Dibutyl phthalate (DBP)
• Benzylbutyl phthalate (BzBP)
– exposure to high doses during the
fetal period
• lowered testosterone levels
• testicular atrophy
• Sertoli cell abnormalities in male
animals
• Higher doses can cause ovarian
abnormalities in female animals
 Phthalates
• The relation between prenatal
exposure to phthalates and its effect
on the anogenital distance (AGD) and
other genital measurements in male
infants was assessed.
• Despite the limited sample, the results
showed a significant decrease in the
anogenital index with increasing
phthalate score.
Swan et. al. (August 2005)
• The median concentration of phthalate
levels was below that found in one-quarter
of the female population in the United
States, based on a nationwide survey.
• This supports the hypothesis that prenatal
exposure to phthalate at environmental
levels can adversely affect male
reproductive development in humans as
well as rodents.
Swan et. al. (August 2005)
 Clinical Correlation
• Treatment of the
hyperpigmentation will have to
wait until 6months postpartum
• No evidence has been found to
support any specific topical
product to prevent stretch
marks
 Summary
• MT, 19 y.o., G1P0
• PU 19 weeks AOG, by LMP,
NIL
• G1P0
• Physiologic skin changes
– Linea nigra
– Striae gravidarum
 Summary
• There are still a number of
chemicals that haven’t been
investigated.
• Many of the evidence given are
at most expert opinions since
there are very limited studies
made on these cosmetic
products and procedures.
 Summary
• Exposure to phthalates cannot
be prevented but we can
advise our patients to limit their
exposure by choosing products
that do not use these
ingredients.
 Lipsticks with lead levels higher
than 0.1 ppm

Maybelline NY Moisture Extreme Scarlet 0.11 LʹOreal CT 08/27/07

Simmer

Cover Girl Incredifull Lipcolor Maximum 0.12 P&G CA 08/23/07

Red

Peacekeeper Paint Me Compassionate 0.12 Peacekeeper MA 08/27/07

Maybelline NY Moisture Extreme Midnight Red 0.18 LʹOreal MN 08/26/07

Maybelline NY Moisture Extreme Cocoa Plum 0.19 LʹOreal CA 08/23/07

Dior Addict Positive Red 0.21 LVMH CA 08/23/07

Cover Girl Continuous Color Cherry Brandy 0.28 P&G CA 08/23/07

LʹOreal Colour Riche True Red 0.50 LʹOreal MN 08/26/07

Cover Girl Incredifull Lipcolor Maximum 0.56 P&G MN 08/26/07

Red

LʹOreal Colour Riche Classic Wine 0.58 LʹOreal CT 08/27/07

LʹOreal Colour Riche True Red 0.65 LʹOreal CA 08/23/07

 References
• Tunzi, Marc MD and Gary R. Gray, DO. Common Skin Conditions During
Pregnancy. American Family Physician, Vol. 75, No. 2, January 2007, 211-218.
• Osman, Hibah MD, et.al. Risk factors for the development of striae gravidarum.
American Journal of Obstetrics and Gynecology, Vol. 196, No. 62, 62.e1-62.e5.
• http://www.pds.ph.org/ “The Philippine Dermatological Society Position Paper
on Glutathione”, prepared by: Lonabel A. Encarnacion, MD, FDPS
• Mahe, A., et.al. The cosmetic use of skin-lightening products during pregnancy
in Dakar, Senegal: a common and potentially hazardous practice. Transactions
of the Royal Society of Tropical Medicine and Hygiene (2007), Vol. 101, 183-
187.
• Young GL, Jewell D. Creams for preventing stretch marks in pregnancy.
Cochrane Database of Systematic Reviews 1996, Issue 1. Art.No.: CD000066.
DOI: 10.1002/14651858.CD000066.
• Koren, Gideon MD, FRCPC. Hair care during pregnancy. Canadian Family
Physician, Vol. 42: April 1996, 625-626.
• Department of Health and Human Services, Centers for Disease Control and
Prevention: Third National Report on Human Exposure to Environmental
Chemicals, July 2005.
• Swan, S H, et.al., Decrease in Anogenital Distance among Male Infants with
Prenatal Phthalate Exposure. Environmental Health Perspectives, Vol. 113, No.
8: August 2005, 1056-1061.
Thank you