Pregnancy and Dermatologic Surgery

[Dermatologic surgery during pregnancy and lactation]

It may be necessary for patients to undergo (dermato-)surgical procedures during pregnancy or lactation. Often, there are no drug approvals or guidelines in this context. The following article describes the most common dermatologic surgical conditions during pregnancy and lactation, as well as the special therapeutic considerations and risks to be aware of during treatment. Dermatosurgical procedures are subject to strict indications. Most of these procedures can be performed during pregnancy, but the risks to the mother and fetus must be carefully weighed against the disadvantages of nonsurgical therapy. Although surgery can be performed safely in any trimester, the second trimester and immediate postpartum period are optimal. Surgery should not be delayed for melanoma or high-risk skin cancer. Perioperative positioning and choice of analgesics, antiseptics, anesthetics and antibiotics must be considered carefully to avoid risks to the patient, fetus and infant.

Practice patterns regarding combination treatments and laser and energy based devices: A survey of American Society for Laser Medicine and Surgery Members

OBJECTIVE

The use of laser and energy-based devices (LEBD) has grown exponentially in recent years, and variations in common practices exist. Our study sought to evaluate the current practice paradigms of leaders in the field of LEBD with regard to antimicrobial prophylaxis, adjuvant topical treatments, use of laser procedures in pregnancy, and combination of procedures.

METHODS

Anonymous surveys were distributed to leading dermatologists in American Society for Laser Medicine & Surgery (ASLMS) via email.

RESULTS

Surveys were distributed to 65 ASLMS members; 37 submitted responses. Routine antiviral prophylaxis is used by 76% for fractional ablative procedures of the face, but only 27% for fractional non-ablative procedures. Routine antifungal prophylaxis was used by a minority (16%) for ablative procedures, whereas antibacterial prophylaxis was used by 68%, with varying antibiotics. Wide variations exist in skin preparation and topicals used post-laser treatment. Most respondents feel comfortable combining same-day LEBD and botulinum toxin injections, specifically vascular or Q-switched/picosecond lasers. Most respondents avoid performing LEBD during pregnancy.

CONCLUSIONS

Expert consensus in a rapidly growing field sheds light on common, reliable practices. However, even at the expert level, variations exist. Further high-quality research is needed to standardize and update guidelines.

Dermatologic and cosmetic procedures in pregnancy

Background:

Materials and Methods:

Results:

A Narrative Review of the Complex Relationship between Pregnancy and Eye Changes

Pregnancy is a condition often characterized by changes that occur in different parts of the body. Generally, the eyes suffer several changes during pregnancy that are usually transient but may become permanent at times. This may occur due to the release of placental hormones and those of maternal endocrine glands and fetal adrenal glands. Due to hormonal influences, physiological ocular changes during pregnancy have been shown in Caucasian women, so corneal sensitivity, refractive status, intraocular pressure, and visual acuity may change during pregnancy. Within this review, all studies that referred to physiological aspects and to changes of ocular pathology of pregnancy, the effect of the pregnancy on pre-existing (diabetic retinopathy, neuro-ophthalmic disorders) eye disorders, postpartum ocular changes, the intraocular pressure and the effect of hypotensive ophthalmic medicine during pregnancy, the connection between pregnancy and the neuro-ophthalmic pathology, as well as the role of anesthesia were analyzed.

Management of Melanoma during Pregnancy: A Case Series of 11 Women Treated at NYU Langone Health

OBJECTIVES

Melanoma is one of the most common malignancies diagnosed during pregnancy. This study examined the impact of pregnancy on management decisions of melanoma patients treated at NYU Langone Health (NYULH).

METHODS

We analyzed data for patients who were pregnant at initial or recurrent melanoma diagnosis at NYULH from 2012 to 2019 with prospective protocol-driven follow-up.

RESULTS

Of the 900 female patients accrued during this period, 11 women in the childbearing range were pregnant at melanoma diagnosis. Six patients presented with early (stage 0 or I) disease and five with advanced (stage III or IV) melanoma. Women with early stage disease had normal deliveries and minimal changes to their treatment timeline and regimen. However, patients with more advanced stage disease opted for either termination of the pregnancy or early delivery and altered treatment timelines because of pregnancy.

CONCLUSION

Both melanoma stage and gestational age at diagnosis contribute to the differences in the therapeutic management of melanoma in pregnant women. Given the complexity and variety of each case of melanoma during pregnancy, informed discussion between patients and physicians allows for individualized treatment plans that address each patient's unique situation.

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.

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.

A Review of Local Anesthetics: Minimizing Risk and Side Effects in Cutaneous Surgery

BACKGROUND

The specialty of dermatology relies heavily on local anesthesia for diagnosis and management of skin disease. The appropriate selection, preparation, administration, and monitoring of these medications affect surgical outcome and patient safety and satisfaction.

OBJECTIVE

To perform a comprehensive literature review of the side effects and risks associated with local anesthetics used in cutaneous surgery. Current recommendations to reduce risk and minimize side effects are reviewed.

MATERIALS AND METHODS

A comprehensive review of the English-language medical literature search was performed.

RESULTS

No current review articles of the side effects and risks of local anesthetics were identified. This review serves to discuss local anesthetics commonly used in dermatology and cutaneous surgery along with practical information regarding prevention of adverse outcomes and addressing local and systemic reactions when they arise.

CONCLUSION

Local anesthetics commonly used in cutaneous surgery have potential risks and side effects. Appropriate selection and utilization of local anesthetics and knowledge of the means to prevent and address these risks can impact surgical outcomes, patient satisfaction and safety, and ultimately patient experience in the dermatology clinic.

Dermatologic therapy in pregnancy

Patients present during pregnancy with a variety of dermatologic conditions, most of which can be treated conservatively with topical medication by a primary obstetrician if he or she is familiar with common treatment options. Patients with moderate to severe forms of dermatologic disease or those requiring systemic therapy should be treated in consultation with a dermatologist. Dermatologic surgery can be performed safely in the second trimester using local anesthesia if needed.

Pregnancy and dermatologic therapy

Dermatologists should be familiar with medication safety in pregnancy to be able to prescribe safely and confidently to pregnant women or women who may become pregnant during the course of treatment for dermatologic conditions. Topical medications should be considered first-line therapy for pregnant women, but certain systemic medications are safe to use in pregnancy and may be prescribed if necessary. Dermatologic surgery may be performed during the second trimester of pregnancy with proper positioning, but elective procedures should be delayed until the postpartum period.

Melanoma in pregnancy

Since the early 1950s clinicians have been concerned about the impact of pregnancy on malignant melanoma (MM). Case reports and case series described a grave prognosis for women diagnosed with MM during pregnancy. Today MM in pregnancy takes on enhanced significance as more women delay childbearing into their 30s and 40s, and the incidence of MM during pregnancy may be expected to increase. In addition, relative immunosuppression during pregnancy theoretically may favor the potential for MMs to behave more aggressively. This article compiles the most recent clinical, epidemiologic, and laboratory studies to guide clinicians in addressing the issue of melanoma in pregnancy. Herein we address the prognosis, characteristics, evaluation, treatment, and how to counsel women diagnosed with MM during pregnancy, including the potential consequences for the fetus. Overall, our analysis reveals that there is no effect on survival in women diagnosed with localized MM during pregnancy; likewise, pregnancies prior or subsequent to a diagnosis of MM do not impact prognosis. Strong epidemiologic evidence shows no enhanced risk of developing MM associated with oral contraceptive pill use. Although a smaller number of studies have addressed hormonal replacement therapy and risk of MM, these studies do not suggest a higher risk of MM. As for the fetus, risk of metastasis to the placenta and/or fetus is extremely low, and seems to occur exclusively in women with widely metastatic MM.

[Melanocytic nevi, melanoma, and pregnancy]

Malignant melanoma is among the malignant tumors whose incidence has risen markedly in recent decades. For many years the medical community debated the potential adverse effects of female hormones (whether of exogenous or pregnancy-related endogenous origin), on melanocytic nevi and malignant melanoma. Given that women have been delaying pregnancy until their thirties or forties and that the incidence of malignant melanoma increases in those decades, the likelihood of this tumor developing during pregnancy has increased. Recent clinical and experimental evidence has suggested that pregnancy does not affect prognosis in malignant melanoma and that it does not seem to lead to significant changes in nevi. This review examines the relationship between malignant melanoma and hormonal and reproductive factors. Evidence was located by MEDLINE search (in PubMed and Ovid) for articles in English and Spanish for the period from 1966 to March 2010; additional sources were found through the reference lists of the identified articles.