Skin darkening during pregnancy

Skin darkening during pregnancy also called hyperpigmentation, occurs in up to 90% of pregnant women. This darkening of the skin may occur in specific areas of the body such as the midline of the tummy as in ‘linea nigra’ or on the face as in ‘the mask of pregnancy’ also known as melasma ¹⁾. Alternatively, the darkening of the skin may affect skin spots such as scars and freckles, may affect the nipples and area around the nipple (the areola), the external genitalia, or areas of increased friction including the armpits (axillae) or the inside of the thighs (groin). Women who are dark haired and have dark complexions are more likely to develop some degree of skin darkening, and it is also more likely to be more pronounced in these women also.

You may also develop stretch marks on your body, particularly around your stomach where your skin is stretching to accommodate your growing baby.

Figure 1. Mask of pregnancy

Figure 2. Linea nigra

When does skin darkening during pregnancy occur?

Skin darkening during pregnancy (hyperpigmentation) tends to develop in the first trimester of pregnancy and it is considered as one of the earliest signs of pregnancy.

However, in first pregnancies its appearance may be delayed until several months into the pregnancy.

How long does skin darkening during pregnancy last?

The increased pigmentation can continue to progress during the pregnancy until delivery.

The darkened areas almost always lighten following delivery of the baby, however, this may take months and in some women it will not completely fade.

In subsequent pregnancies it may appear earlier and darker than previously.

What causes skin darkening during pregnancy?

The exact cause is not known but it is thought to occur due to increased levels of hormones produced in pregnancy. These include:

• Melanocyte stimulating hormone (MSH) – a hormone that stimulates melanocytes – the cells in the body that produce pigment and give rise to darker skin, freckles, birthmarks (naevi) etc.;
• Estrogen; and
• Progesterone.

Skin darkening during pregnancy remedies

The darkened areas that developed in your pregnancy will generally fade following the delivery of your baby. Preventative measures and treatment options are limited.

It is recommended that pregnant women wishing to minimize skin darkening use a broad spectrum combined UVB+UVA sunscreen with SPF 50+ on sun exposed areas, wear appropriate protective clothing, avoid sunbathing and excessive sun exposure.

Current skin cancer prevention campaigns recommend that individuals use sun protection such as hats, clothing, sunscreen, sunglasses and/or shade during periods when ultraviolet (UV) index is high, typically between 10 am and 3 pm. Given that the sun is a major source of vitamin D, essential for bone health, there needs to be a balance between exposure and protection. The amount of sun exposure you need to prevent vitamin D deficiency varies depending on your skin type, location, season and time of day. Generally 30 minutes of sun exposure to the neck, hands and arms when the UV index is low gives sufficient exposure to maintain vitamin D levels.

The skin changes brought about by the increased levels of hormones in pregnancy are not associated with the development of skin cancer. However, if you have developed these skin changes from increased sun exposure you may be at risk of developing a skin cancer not related to these skin changes given that sun exposure is a risk factor for the development of skin cancer. There is no strong evidence that pregnancy is associated with changes in nevi (moles). Therefore if you have a mole that has changed in its appearance it should be looked at by your doctor. If suspicious for a cancer, your doctor can arrange for a biopsy of the mole.

There are multiple creams/lotions that can be used to help reduce the skin changes. These are typically prescribed by doctors who specialize in the treatment of skin conditions called dermatologists. Treatment is usually only used in those women in which the skin changes do not resolve spontaneously following delivery of the baby and are troublesome for the mother. Treatment is not recommended during pregnancy for several reasons:

• The hormones that are the cause of the skin condition persist during pregnancy, and hence it is harder to treat;
• Most cases resolve on their own once the baby is born, although this may take some months; and
• The treatments used can be harmful to the developing baby.

During your pregnancy or after the birth of your baby, you can consider camouflaging the skin changes with cosmetics. Foundations and powders with a white or yellow undertone can minimize the appearance.

If the areas fail to fade following the delivery of your baby, you may want to discuss this with your doctor who may be able to advise you further on treatment options or may refer you to a doctor who specializes in the treatment of skin conditions (a dermatologist). Depending on the area involved, treatment options may include:

• Creams such as hydroquinone, tretinoin and/or fluocinolone acetonide
• Chemical peels
• Dermabrasion
• Laser therapy

Treatments your dermatologist may prescribe

• Use bleaching agents (hydroquinone 4%) carefully. Do not apply these agents to the normally pigmented surrounding skin, as normal skin may also be bleached. Use hydroquinone under the supervision of a dermatologist, as side effects, such as darkening of the skin, may occur.
• Hydroquinone is often irritating and may require the use of 1% hydrocortisone cream, which may also help with the hyperpigmentation. Combination therapy with tretinoin cream may also be helpful.
• Superficial chemical peels (application of an acid to remove the top layers of the skin) and microdermabrasion (a facial sanding technique) may offer additional help.
• A topical agent, azelaic acid, may be helpful.
• Laser therapy has not yet been shown to be satisfactory treatment. Melasma may return and hyperpigmentation may develop in the treated area.

When you embark on a prescription skin lightening program with your dermatologist, it is often best to balance your entire skin care regimen with gentle, non-irritating cleansers and moisturizers. Keep your skin well hydrated as dry skin causes hyperpigmentation.

NOTE: it is important to understand that you must commit to a careful regimen of sun protection when using any of these medications – it is not optional. You must use an SPF 30 or greater every day on areas that are being treated. If you don’t protect those areas from sun exposure, they will continue to darken, making the situation even worse.

Hydroquinone: Handle with care

Hydroquinone is considered the “gold standard” when it comes to effectiveness. However, some dermatologists consider it a somewhat controversial medication because it can cause skin damage at high concentrations. In fact, hydroquinone has been banned in some countries because of fears of a cancer risk. It works by blocking a critical step in the synthesis of melanin.

When hydroquinone was first introduced (at 2% strength), there was good science and data behind its safety as well as its effectiveness in inhibiting melanin production. What concerns me most is that newer and stronger forms have flooded the market with much less scientific analysis. Hydroquinone is now available in concentrations up to 12%; note that all products containing 3% and greater are to be prescribed by a dermatologist.

It must stressed that there is a real danger in self-medicating with hydroquinone at higher concentrations without professional guidance on proper use, risks, and side effects. There are a lot of new choices when it comes to hydroquinone products. Various brands now offer hydroquinone combined with other ingredients that are thought to increase its potency such as tretinoin, glycolic acid, vitamin C, and steroids. But what is the best formulation? Is there any increased risk of cancer in patients who use hydroquinone? How long is it safe to use hydroquinone? There are many unanswered questions.

What do dermatologist know for sure? To start, hydroquinone will bleach skin without discrimination, so it should NOT be used on the full face. It should only be used as a “spot treatment,” under a dermatologist’s supervision. Care and discipline must be practiced to get the desired result. If it is used beyond the borders of affected areas, it may cause lightening of a larger area than intended (“halo effect”). Halos are not easily reversed even when the hydroquinone is discontinued. Lastly, over-the-counter as well as prescription strength hydroquinone should be AVOIDED during pregnancy and while breast-feeding.

Azelaic acid: Treat both acne and pigmentation disorders

Azelaic acid works wonders for acne, destroying acne-causing bacteria before they have the chance to cause outbreaks. An additional benefit is that it is a very effective treatment for post-inflammatory hyperpigmentation, much of which is caused by acne outbreaks. So it works on two levels – improves acne and some of the pigmentation disorders that appear with it.

Azelaic acid reduces melanin production by depressing certain enzymes necessary for the synthesis of melanin. While not as potent as hydroquinone, Azelaic acid offers many benefits for evening skin tone. You can use it all over the face as well as a spot treatment. It is well tolerated by most people with little risk of irritation even when combined with other acne medications and skin lighteners. Another advantage of azelaic acid is that in general, it is considered safe to use during pregnancy.

Corticosteroids: Can have serious side effects

Corticosteroids work on two levels – they decrease inflammation, which causes hyperpigmentation, and they decrease the function of melanocytes without destroying them. By adding corticosteroids to other lightening agents, it enhances their ability to work and decreases the likelihood of irritation as well as the inflammation that can cause hyperpigmentation.

Corticosteroids come in a wide range of strengths. Potent forms can have serious side effects in as little as two weeks if they are misused. In addition, patients who use steroids for an extended period of time will develop a dependency on them and may find it very difficult to stop using them. Therefore, corticosteroids should only be used with your dermatologist’s close supervision. Unfortunately, due to lax and less-than-uniform regulatory processes around the world, it is possible to get corticosteroids without a prescription; however this can be risky, and dermatologist would strongly advise against it.

Retinoids: Good for skin rejuvenation, too

It is easy to find retinol listed in skin care products, but it is not nearly as potent or effective as the prescription strength retinoids such as tretinoin (Retin-A®), adapalene (Differin®), and tazarotene (Tazorac®). These medications can actually repair damaged DNA in the skin and were initially manufactured to treat acne. Dermatologists learned that retinoids can also be a good treatment for the post-inflammatory hyperpigmentation often caused by acne.

Retinoids influence pigmentation by speeding up turnover in the skin, gradually eliminating anything sitting on the top layers. That sloughing process automatically begins to slow down in your mid twenties. Retinoids reverse that effect by producing a faster rate of cell turnover as well as eliminating abnormal melanin in the top layer of skin. They do not work by bleaching the skin, but rather returning the skin to its natural color. Retinoids are useful in treating melasma and acne scars by reducing the amount of excess melanin and distributing it more evenly.

While tretinoin, adapalene and tazarotene are only supposed to be prescribed by a dermatologist, they can be obtained without a prescription over the Internet. These medications should be used under the supervision of a dermatologist. So be very cautious about the source. Also, all retinoids are not created equally; some should be avoided altogether while others must be avoided during pregnancy or breastfeeding.

Mequinol: Excellent for sunspots

Mequinol is available in the U.S. in a 2% concentration, usually combined with tretinoin, and is harder to get without a prescription. Mequinol does not damage the melanocyte like hydroquinone, and it can be an excellent treatment for sunspots and other causes of hyperpigmentation.

However, dermatologist urge caution to those with darker skin tones because mequinol can actually cause post-inflammatory hyperpigmentation for unknown reasons. It can also cause irritation in all who use it and must NOT be used during pregnancy or breast-feeding.