Safety of Antifungals in Pregnancy and Lactation

​Is it ok to take an antifungal while pregnant or breastfeeding?

Credits: "Ryan Franco at Unsplash.com"
Share

From nail infections to itchy scalp to yeast infections, skin fungal infections are very common in the general population. Unfortunately, pregnancy is not immune to these conditions and many women who face skin fungus in pregnancy require treatment. However, not all antifungals are safe to use during pregnancy. Many antifungals are available over the counter and the safety of antifungal medications applied directly to the skin (topical) and those taken in oral form (systemic) will be reviewed.

It is worthwhile to note that fungi that infect humans come in two major forms: candida (yeast) and tinea (dermatophytes/mold). Candida or yeast often grow in moist environments such as the folds of the skin, oral cavity, and vaginal and anal areas. Infection with Candida is usually red and itchy. Tinea infections include a group of mold/dermatophyte infections, which include Trichophyton, Epidermophyton, and Microsporum species. These infections can take place anywhere on the skin including the nails and hair. The symptoms vary by type of infection but often times the skin can get discolored and appear white, brown, tan, or pink. Medication used to treat fungal infections is often different for these two classes of critters.[1]

 

Topical Antifungals: Safe Medications in Pregnancy 

Topical antifungals include nystatin, clotrimazole, miconazole, terbinafine, ciclopirox, and selenium sulfide. Table 1 briefly summarizes the information we will discuss. 

The topical form of nystatin is often used to treat superficial fungal infections, most commonly known as candida. This medication is rarely used in oral form because it does not absorb well into the bloodstream when taken orally.[2] It is categorized as pregnancy category A when used as an intravaginal tablet for fungal infections in that area, such as vulvovaginal yeast infections. Its topical form (ointment, powder, cream) has been labeled pregnancy category C, simply because there are no good human or animal studies verifying its safety in pregnancy. However, there are no reports in the literature about negative effects to the fetus when used in pregnancy. It has a lactation category of L1 and is safe to use while breastfeeding.[3]

Clotrimazole is another antifungal commonly used to treat vulvovaginal yeast infection. It has been commonly used to treat these infections in pregnancy and is considered generally safe. A single case was published about its potential association with spontaneous abortion in a patient. However, it was never confirmed to be the cause and there have been no reports since then of negative effects on the fetus when used in pregnant women.[4] In 1999, a large study with more than 18,000 patients concluded that clotrimazole use during pregnancy does not significantly correlate with abnormalities in the fetus.[5] It is pregnancy category B and lactation category L1 and safe to use while breastfeeding.[3] Some clinicians prefer to use this first to treat vulvovaginal yeast infection before trying nystatin in pregnant women.[4] A related topical agent, miconazole, has also been used safely in many pregnancies and there have been no birth defects in babies reported. It is labeled as pregnancy category C. It has an L2 lactation rating and is most likely safe to use during breastfeeding.[6]

Topical terbinafine is often used to treat athlete’s foot, jock itch, ringworm, and a variety of other fungal infections. It is assigned pregnancy category B as animal studies with the use of this agent have not demonstrated any adverse effects to the fetus. Also, topical terbinafine is not greatly absorbed through the skin. It is generally regarded as safe to prescribe during pregnancy.[3,4] It has a lactation category L2 and is not thought to affect breastfeeding.[4]

Ciclopirox is a medication used to treat many of the above-listed conditions. It is usually only used topically and is pregnancy category B. In animal studies, this medication has not been shown to harm the growing fetus when administered either topically or orally to rats, mice, monkeys, and rabbits. Therefore, it can be used topically safely during pregnancy but is not often chosen as a first-line agent. Its effects on breastfeeding are less well known, and it is labeled L3. It should not be chosen as the first-line medication for breastfeeding moms as there are other medications (such as the ones listed above) with more safety data/reports available.[3]

Selenium sulfide is commonly found in shampoos and is used to treat conditions like seborrheic dermatitis (itchy, flaky scalp, aka. dandruff). We would like to focus on this agent since it is so common in over the counter products. It is important to note that it has been labeled pregnancy category C. There have been no animal or human studies conducted to assess the safety of this agent in pregnant women. The current recommendations state that it is safe to use in very local areas for limited amounts of time.[3] It has a lactation rating of L3. It is generally considered safe to use during lactation, but there is one reported case of breast milk production suppression in a woman using selenium disulfide to treat a condition called tinea versicolor, but this is the only known reported case of such an effect.[7]

Table 1 - Topical Antifungals and Pregnancy and Lactation Categories

Topical Antifungal

Pregnancy Category

Lactation Category

Nystatin

A (vaginal)- safe to use

B (topical)- safe to use

L1- safe to use

Clotrimazole

B- safe to use

L1- safe to use

Miconazole

C-Physicians generally consider safe to use

L2- Most likely safe during breastfeeding

Terbinafine

B- safe to use

L2- generally safe to use

Ciclopirox

B- safe to use, but not first-line, try something else first.

L3- Avoid if possible, very little data.

Selenium Sulfide

C- use in local areas for short time

L3- One report of milk production suppression, therefore, L3 rating, but physicians believe it is most likely safe during breastfeeding.

 

Oral Antifungals: Safe Medications in Pregnancy 

Five commonly used oral antifungal agents include griseofulvin, terbinafine, and three antifungals in the “azole” category including fluconazole, ketoconazole, and itraconazole. Table 2 provides a summary of the safety categories and general recommendations.

Griseofulvin is an oral antifungal used to treat fungal infections, such as ringworm of the scalp known as tinea capitis. It is categorized as pregnancy category C and is generally not recommended during pregnancy due to very limited data. There was one reported case of conjoined twins with the use of this agent as well.[8] It has a lactation category of L2, but due to minimal data, most clinicians recommend avoiding the agent while breastfeeding. [3]

The “azole” class of antifungals are used to treat mold and yeast infections, including oral or vulvovaginal yeast infections.[9] However, these are all pregnancy category C, and human studies and reports have demonstrated risk to the fetus. Specifically, exposure to these agents in the first trimester can result in neurologic, cardiac, bone, and facial defects in the baby. These should be avoided during pregnancy. All of these agents are lactation category L2. Fluconazole has the most data on lactation and is likely safe to use while breastfeeding. Itraconazole has been shown to reach high concentrations in breast milk and may be best to avoid while breastfeeding. There is very limited data on lactation and ketoconazole—experts say that it is likely safe, but more data are needed to confirm this.[3] 

Oral terbinafine is often used to treat fungal infections of the finger and toenails, and sometimes fungal infections of the scalp in older children and adults. It does not treat yeast infections such as vaginal or oral candida. Although there have not been any published reports of harmful effects to the fetus in pregnant women who have taken this medication, there is very limited data on its pregnancy safety. It is currently labeled pregnancy category B. Since the medication is used to treat non-life threatening conditions (nail and scalp fungal infections), it is recommended that oral terbinafine be avoided during pregnancy. It has a lactation category of L2. For breastfeeding mothers, the current recommendation states that oral terbinafine should only be used for short time periods.[3]

Table 2 - Oral (Systemic) Antifungals and Pregnancy and Lactation Categories

Oral Antifungal

Pregnancy Category

Lactation Category

Griseofulvin

C- limited data, do not use in pregnant women if it can be avoided

L2- but limited data, so again, avoid if possible

Fluconazole

C- avoid in pregnancy, birth defects reported

L2- most data out of all the “azole” drugs, likely safe to use

Ketoconazole

C- avoid in pregnancy, birth defects reported

L2-likely safe, but limited data, more data needed to confirm safety

Itraconazole

C- avoid in pregnancy, birth defects reported

L2- reaches high concentrations in breast milk, avoid and try other drugs first

Terbinafine

B - wait to treat with this medication after pregnancy

L2- use only for short period of time

 

Please consult a qualified health care provider/physician to discuss how the information discussed here may be appropriate for your skin care. For any drugs discussed here, please consult the drug package insert for complete prescribing information and for complete information regarding side effects.

For further reading on the topics of fungal infections, pregnancy, and skin care, click on the article links below:

Fungal Microbiome (Mycobiome): The Fungus Among Us

Safety of Anti-Itch Medications During Pregnancy

Skin + Pregnancy: Bye Bye Botox & Lashes, Hello Pregnancy Glow!

Treating Psoriasis in Pregnancy and Lactation

 

 

 

 

* This Website is for general skin beauty, wellness, and health information only. This Website is not to be used as a substitute for medical advice, diagnosis or treatment of any health condition or problem. The information provided on this Website should never be used to disregard, delay, or refuse treatment or advice from a physician or a qualified health provider.

See additional information.

References

  1. Habif TP. Clinical dermatology. (2015). Elsevier Health Sciences.
  2. Pilmis B, Jullien V, Sobel J, et al. Antifungal drugs during pregnancy: an updated review. J Antimicrob Chemother.2015;70(1):14-22; PMID: 25204341 Link to Research
  3. Murase JE, Heller MM, Butler DC. Safety of dermatologic medications in pregnancy and lactation: Part I. Pregnancy. J Am Acad Dermatol.2014;70(3):401 e401-414; quiz 415; PMID: 24528911 Link to Research
  4. Mullegger RR, Haring NS, Glatz M. Skin infections in pregnancy. Clin Dermatol.2016;34(3):368-377; PMID: 27265075 Link to Research
  5. Czeizel AE, Toth M, Rockenbauer M. No teratogenic effect after clotrimazole therapy during pregnancy. 1999;10(4):437-440; PMID: 10401880 Link to Research
  6. Hale EK, Pomeranz MK. Dermatologic agents during pregnancy and lactation: an update and clinical review. Int J Dermatol.2002;41(4):197-203; PMID: 12031026 Link to Research
  7. Sugathan P, Riyaz N. Suppression of lactation by selenium disulfide. Int J Dermatol.1990;29(3):232-233; PMID: 2335423 Link to Research
  8. Rosa FW, Hernandez C, Carlo WA. Griseofulvin teratology, including two thoracopagus conjoined twins. 1987;1(8525):171; PMID: 2880014 Link to Research
  9. Cottreau JM, Barr VO. A Review of Antiviral and Antifungal Use and Safety during Pregnancy. 2016;36(6):668-678; PMID: 27139037 Link to Research