Taking Antifungals During Pregnancy and Breastfeeding – Is It Safe?

Fungal infections come in all shapes and sizes, from an itchy scalp to yeast infections. Unfortunately, pregnant women are also subject to getting these infections which can make them feel uncomfortable at the very least. Usually, antifungals are used to combat these infections. However, not all of these medications can be used by pregnant or lactating women as they might harm their and their baby’s health.

Fungal infections are usually of two types- yeast infections or mould infections. Yeast infections occur in moist environments such as at skin folds, the vagina, or anus. Mould infections can infect any part of the body, including the hair and nails. Medications for these two types of fungal infections are different. In the following post, we discuss the safety and recommendations regarding the use of antifungal drugs during gestation.

Are Antifungals Safe for Pregnant And Lactating Women?

There are two types of antifungals you can take – oral and topical creams. Both these types of medications use different ingredients to combat the infection. However, not all ingredients are safe for pregnant women and using antifungal creams during pregnancy must be done with caution. Why? Because antifungal medications, like many other drugs, may cross the placenta and affect fetal development. Hence, your safest bet for using antifungal medication is to consult your doctor first. She will be able to tell you if they are safe for you to use and if you can use the same after birth, during lactation. Mostly, topical antifungal treatments are preferred during pregnancy and breastfeeding because they have lower chances of entering the bloodstream.

Topical Antifungals That Are Safe to Use During Pregnancy and Breastfeeding

Some antifungal medications are considered safe for pregnant and breastfeeding women, while others carry higher risks of complications. It’s crucial to be aware of which medications fall into each category. In most cases, your doctor will prescribe antifungals that do not possess steroids, which come in different categories. The list provided below shows safe topical antifungals your doctor may prescribe. It is recommended that you try one type of antifungal for a short period of time to see if it has any adverse reaction. In case of any allergic or adverse reaction, your doctor may recommend you switch to oral, or they may switch to other topical antifungals mentioned below.

1. Clotrimazole: A Trusted Choice

Clotrimazole is a commonly recommended antifungal for pregnant and breastfeeding women. It’s used to treat various fungal infections, including yeast infections. Since a very minimal amount is absorbed into the bloodstream, it poses little risk to the baby and is deemed safer during pregnancy.

2. Nystatin: A Go-to Option

Nystatin is considered safe because it’s poorly absorbed in the gut. It is often prescribed to treat oral thrush in babies and nipple thrush in breastfeeding mothers. Nystatin is no risk to the foetus in the first trimester, plus the possibility of fetal harm appears very negligible.

3. Miconazole: Balancing Effectiveness and Safety

Miconazole is another antifungal option that can effectively treat fungal infections. Studies suggest that it’s unlikely to harm the baby when used topically. However, it’s advisable to avoid miconazole during the first trimester.

4. Terbinafine: Consultation Required

Terbinafine was approved for use in dermatophytic infections in the late 90s. It is considered safe to use topically during pregnancy and lactation under the guidance of a healthcare provider. Topical Terbinafine is used to treat jock itch, athlete’s foot, ringworm, and other fungal infections.

5. Ciclopirox Oleamine: Consultation Required

Ciclopirox Oleamine is an antifungal agent commonly used in topical formulations to treat a range of fungal infections. While topical medications generally have a lower risk of systemic absorption, there is limited research specifically focusing on its effects on pregnant individuals and developing foetuses. Similar to pregnancy, limited information is available on its effects during breastfeeding. Consult your healthcare provider to make an informed decision. Healthcare providers should only prescribe Ciclopirox Olamine Cream during pregnancy if the potential advantages outweigh the potential risks to the developing foetus.

6. Selenium Sulfide: Limited Use Only

Selenium sulfide is a common agent in over-the-counter products like shampoos and treats conditions like seborrheic dermatitis. No animal or human studies have been conducted to assess this agent’s safety in pregnant women. The current recommendations state that it is safe to use in very local areas for a limited time. It is likely safe to use during lactation. Still, only one case reported breast milk production suppression in a woman who used selenium disulfide to treat a condition called tinea versicolor.

Disclaimer: When you have a fungal infection, never self-medicate. This is one of the most dangerous things you can do when pregnant, as some over-the-counter antifungal creams come with steroids which can cause premature labour.

Oral Antifungals That Are Safe During Pregnancy and Nursing

In case the topical antifungals are not enough, or your body reacts in an adverse and ill manner to the topical creams, your doctor may decide to put you on a course of oral tablets or capsules. Oral antifungals come in numerous doses, so be sure to talk to your doctor and ask them for advice on dosages before going on these medications. Never attempt to take over-the-counter antifungal capsules or tablets; these could have grave repercussions. It is essential that you follow medical advice while taking these types of medication. With oral medication, never stop the dose early or late. See the course through unless your doctor indicates the need for an alternative. They may declare the need for a switch of oral categories if your body reacts badly to one type of antifungal or if one type seems ineffective.

Since antifungals need time to treat infections, around 6–12 weeks, this makes all oral antifungal agents to be strictly avoided in 1st trimester, especially in mild to moderate derma infections.

There have been reports of congenital abnormalities in the foetus and spontaneous abortions attributed to oral antifungals. Oral agents, including fluconazole, ketoconazole, itraconazole, voriconazole, and griseofulvin, can cause potential maternal complications, including birth defects like musculoskeletal malformations, congenital heart anomalies, eye defects, and spontaneous abortions. These are best avoided in pregnancy due to the lack of human data.

Below are the two antifungal agents we can consider during pregnancy and breastfeeding, but with caution:

1. Terbinafine

Terbinafine is the safest oral antifungal choice in case of recurrent dermatophytosis. In a Danish study spanning 20 years, it was found that oral or topical terbinafine use in pregnancy is not associated with major malformations or spontaneous abortion.

2. Low-Dose Fluconazole

Low-dose fluconazole (up to 150 mg) may be used in vaginal candidiasis. But it is important to avoid higher doses in pregnancy strictly. It is better to wait to use it after pregnancy or use it briefly during breastfeeding, both only after a doctor’s consultation.

A 2009 study reported that infants exposed to itraconazole during the first trimester did not show an elevated risk of significant congenital abnormalities. However, the group exposed to itraconazole exhibited higher rates of both spontaneous and induced abortion compared to the control group. Larger studies are needed to validate and substantiate these findings.

Disclaimer: Never attempt to self-prescribe oral antifungals during pregnancy. Many over-the-counter antifungal tablets come with high doses of anabolic steroids. This type of steroid can be very harmful to your body, and its side effects might range from premature labour and miscarriages to lowered blood pressure and delayed labour. Some over-the-counter antifungals may cause hormonal changes if taken without care. Talk to your doctor, follow up on appointments and complete the dosage prescribed; if you don’t, the chances of a recurrence of the infection are higher. The only time that it is considered okay to not finish the course is if you experience any side effects or allergic reactions due to the medication, in which case, your healthcare professional will switch chemical bases for the antifungals.

The use of antifungals during pregnancy can be dangerous when done without caution; this is because most antifungal medications and creams also contain substances like powerful steroids. When using antifungals, always do so with the supervision and consultation of your trusted medical welfare professional. It is essential that your caregivers and partners all understand the need and complications of antifungals during this very sensitive time in your life. Make sure that you go to your medical care appointments with caregivers and partners. If the fungal infection is extremely bad, your doctor may decide to put you on a combination of oral and topical antifungal medication. Remember to follow the dosage to the letter and never over-medicate or under-medicate. Avoid self-medication and self-prescription of drugs during pregnancy, and avoid over-the-counter medication altogether unless your doctor has explicitly told you it is safe.

References/Resources:

1. Patel. M. A, Aliporewala. V. M, Patel. D. A; Common Antifungal Drugs in Pregnancy: Risks and Precautions; J Obstet Gynaecol India. PubMed Central; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8617216/; December 2021

2. Patel. V. M, Schwartz. R. A, Lambert. W. C; Topical antiviral and antifungal medications in pregnancy: a review of safety profiles; J Eur Acad Dermatol Venereol; PubMed; https://pubmed.ncbi.nlm.nih.gov/28449377/; September 2017

3. Pilmis. B, Jullien. V, Sobel. J, et al.; Antifungal drugs during pregnancy: an updated review; Journal of Antimicrobial Chemotherapy; Volume 70, Issue 1, Pages 14–22; Oxford Academic; https://academic.oup.com/jac/article/70/1/14/2911295; January 2015

4. LABEL: CICLOPIROX OLAMINE cream; DailyMed – National Library of Medicine; https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=5c585aa5-7d2d-e798-c0bd-d602574d643c.

5. 6. Zhu. Y, Bateman. B. T, Gray. K. J, Hernandez-Diaz. S, et al.; Oral fluconazole use in the first trimester and risk of congenital malformations: population based cohort study; BMJ; PubMed Central; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237981/; May 2020

6. Andersson. N. W, Thomsen. S. F, Andersen. J. T; Evaluation of Association Between Oral and Topical Terbinafine Use in Pregnancy and Risk of Major Malformations and Spontaneous Abortion; JAMA Dermatol; PubMed Central; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057179/; April 2020

7. Budani. M. C, Fensore. S, Di Marzio. M, Tiboni. G. M; Maternal use of fluconazole and congenital malformations in the progeny: A meta-analysis of the literature; Reprod Toxicol; PubMed Central; https://pubmed.ncbi.nlm.nih.gov/33383164/; March 2021

8. King. C. T, Rogers. P. D, Cleary. J. D, Chapman. S. W; Antifungal therapy during pregnancy; Clin Infect Dis.; PubMed; https://pubmed.ncbi.nlm.nih.gov/9827262/; November 1998

9. De Santis. M, Di Gianantonio. E, Cesari. E, et al.; First-trimester itraconazole exposure and pregnancy outcome: a prospective cohort study of women contacting teratology information services in Italy; Drug Saf.; PubMed; https://pubmed.ncbi.nlm.nih.gov/19338381/; 2009

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