Doxycycline for Acne During Pregnancy

What does the evidence say about doxycycline for acne during pregnancy?

1. Tetracycline-class antibiotics like doxycycline used after the fourth month of pregnancy carry a chance of permanent gray or yellowish-brown discoloration of a baby's developing teeth, and may reduce bone growth during exposure, though bone growth appears to return to usual after the medication is stopped. 1
2. Overall, the available information on tetracycline-class antibiotics has not shown a higher chance of birth defects above the background rate of 3 to 5%, and it has been suggested that tetracyclines be avoided after the fourth month of pregnancy unless there is a specific reason for a healthcare provider to prescribe one. 2
3. In a retrospective study of 115 pregnancy-related acne visits, providers favored azelaic acid 15% gel (75.7% of visits) and clindamycin 1% (56.8% of visits) over tetracycline-class antibiotics, which are categorized as a pregnancy-avoid medication class, while benzoyl peroxide, described in guidelines as the preferred first-line option to limit antibiotic resistance, was used less often, in 13.5% of visits. 3
4. Doxycycline reaches only low levels in breast milk, and an infant's actual absorption is further limited because calcium in breast milk reduces how much doxycycline is taken up, so an exclusively breastfed infant receives roughly 6% of the parent's weight-adjusted dose. 4
5. The World Health Organization's assessment, cited by MotherToBaby, notes that when tetracycline is used for 7 to 10 days while nursing, the risk to the infant appears to be low, while a different antibiotic is generally favored for longer courses. 1

Is doxycycline for acne safe in each trimester?

• First trimester. Tooth and bone effects from tetracyclines are tied to exposure after the fourth month, so this specific concern is lower early on, though your provider will likely still reach for azelaic acid, benzoyl peroxide, or clindamycin first for acne at any stage of pregnancy.
• Second trimester. This is when the specific concern kicks in: tetracyclines taken after month four are linked to permanent gray or yellowish-brown discoloration of a baby's developing teeth and can affect bone growth, which is why doxycycline is generally set aside for acne once you're pregnant.
• Third trimester. Providers continue favoring azelaic acid, benzoyl peroxide, or clindamycin over doxycycline through the third trimester for the same tooth and bone reasons. Bone growth effects appear to reverse once the medication is stopped, but tooth discoloration is permanent.