Is tretinoin safe during pregnancy?

What does the evidence say about tretinoin during pregnancy?

1. The general recommendation is to avoid topical retinoid medications like tretinoin during pregnancy, mainly as a precaution based on how the same drug family behaves when taken as an oral pill. 1
2. A 1993 study following 215 pregnancies with first-trimester topical tretinoin exposure found no higher rate of major birth defects compared with pregnancies that weren't exposed. 2
3. A later study of 106 women who used topical tretinoin early in pregnancy found the same rates of miscarriage, major birth defects, and growth measurements as women who didn't use it. 3
4. A small number of published case reports describe babies born with multiple malformations after topical tretinoin exposure, which helps explain why the switch-and-stop advice has stuck even though the larger studies are reassuring. 4
5. The FDA-approved label for Retin-A lists about 30 case reports of malformations gathered over two decades of use, but states that no clear cause-and-effect pattern has been proven and that it should only be used in pregnancy if the benefit outweighs the risk. 5

Is tretinoin safe in each trimester?

• First trimester. This is the highest-priority trimester to stop tretinoin, since major organs are forming early on. Call your prescriber as soon as you know you're pregnant, or ideally before you start trying, so you can switch to a pregnancy-friendlier routine.
• Second trimester. Keep skipping tretinoin through this trimester. If your skin struggles without it, ask your provider or dermatologist about a swap like azelaic acid rather than restarting it on your own.
• Third trimester. Stay off tretinoin for the rest of pregnancy. Most providers are comfortable letting you pick it back up once you've delivered, so this is usually a pause rather than a permanent stop.