Cosmetics In Pregnancy

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 LʹOreal

CT

Incredifull Lipcolor Maximum 0.12 Red

P&G

CA

08/23/07

Peacekeeper

Paint Me Compassionate

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 Red

0.56

P&G

MN

08/26/07

LʹOreal

Colour Riche Classic Wine

0.58

LʹOreal

CT

08/27/07

LʹOreal

Colour Riche True Red

0.65

LʹOreal

CA

08/23/07

Maybelline NY

Moisture Extreme Scarlet Simmer

Cover Girl

0.11

0.12

08/27/07

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, 183187. 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