Skin Conditions in Pregnancy

Skin Conditions in Pregnancy – Medical Conditions in Pregnancy

Due to the immune changes during pregnancy, a woman’s susceptibility to some skin conditions increases during pregnancy. The hormonal and physiological changes in pregnancy also lead to skin changes( like melasma, acne,changes in nails and hair) .

There are three main Dermatoses which are specific to pregnancy.

Atopic eruption of pregnancy

Most common of the pregnancy dermatoses, accounting for about half the cases seen in a pregnancy skin clinic.

‘Atopic Eruption of Pregnancy’ is a new term which encompasses atopic eczema in pregnancy, prurigo of pregnancy, and pruritic folliculitis of pregnancy.

Said to be due to T helper cell activity which increases in pregnancy.

80% women experience it for the first time in pregnancy ( or after a long remission, e.g after childhood) .

About 20% experience exacerbation of pre- existing eczema.

Classified into 2 types-

E type- ( Eczematous type) РSeen in about two -thirds of the cases. Eczematous lesions over atopic areas ( d̩collet̩, and flexural surfaces of the arms and legs, face , neck)

P type- seen in one third cases- Prurigo /Papules- widespread small erythematous papules

on trunk and limbs, and typical prurigo nodules, mainly on the shins and arms.

Severe dryness of the skin is common.

Responds well to treatment.

Treatment- Topical emollients, antihistamines, steroids , ultraviolet B phototherapy.

Implications for the fetus- None, except risk of atopic skin conditions in infancy.

A picture of the E type atopic eruption can be seen here- https://plasticsurgerykey.com/wp-content/uploads/2016/04/B9780723434450100086_gr2.jpg

Polymorphic Eruption of Pregnancy

It is also one of the common dermatoses in pregnancy. ( Incidence is 1 in 160 to 1 in 300 pregnancies)

Seen mainly in primigravidas, associated with excessive abdominal distension( e.g. multiple pregnancy) and excessive maternal weight gain.

Usually presents in third trimester or immediately Postpartum.

True to it’s name, the eruptions are polymorphic — Severely pruritic urticarial papules that merge to form plaques– later becoming more polymorphic, with small vesicles, widespread non-urticated erythema, and targetoid and eczematous lesions

Starts in striae distensae( ‘stretch marks’) . Can spread to the buttocks and thighs, can become generalized.

Umbilical region is typically spared ( exam question) .

Lesions are self limiting- resolve within 4 to 6 weeks independent of delivery.

Link to a picture of polymorphic eruption of pregnancy-

https://dermnetnz.org/topics/polymorphic-eruption-of-pregnancy/

Treatment- Symptom relief. Topical emollients, topical steroids ( systemic steroids almost never needed) . Antihistamines.

Implications for the fetus- None.

Recurrence in subsequent pregnancy- unusual , except in Multiple pregnancy ( exam question).

Pemphigoid gestationis

Incidence- very rare- 1 in 1700 to 1 in 50, 000 pregnancies.

It is an autoimmune conditions.

Other names- pregnancy-related bullous pemphigoid, gestational pemphigoid , herpes gestationis.

Can occur any time after the second trimester to immediately after delivery.Improvement in late pregnancy followed by a flare-up at the time of delivery in 75% of patients.

Lesions typically involve the umbilicus and periumbilical region. ( In contrast to polymorphic eruption of pregnancy) .

Mucosal sparing is a key finding.

The rash usually appears around the umbilicus as urticarial papules and plaques- these join to form bullae, which can extend to the trunk, extremities, palms and soles ( vesiculobullous eruption on urticated erythema) .

After some weeks, large, tense blisters can form around the edge of the rash or in otherwise unaffected areas of the skin.

Diagnosis – made by skin biopsy. Two skin samples are taken- one for histopathology, one for direct immunofluorescence ( which is positive in Pemphigoid Gestationis) .

Indirect Immunofluorescence ( Done on blood or blister fluid) reveals circulating IgG against BP180 or bullous pemphigoid antigen 2. ( For details check the References cited below) .

Treatment- Symptom control. Antihistaminics. Topical and oral corticosteroids.

Systemic corticosteroids are used with caution in pregnancy.

Typical treatment is prednisolone 30–40 mg (0.5 mg/kg body weight) reduced by 5 mg every 3 days to 0. ( Precautions to be kept in mind if systemic steroids are given during pregnancy- Monitor serum electrolytes and blood glucose. Consider ‘stress dose’ of steroid during labor if patient is on systemic steroid)

For non remitting disease, cyclosporine may be needed. ( If it proves impossible to maintain disease control with less than 7.5 mg prednisolone) .

Although it appears to be safe during pregnancy, Cyclosporin is contraindicated in lactation( risk of neonatal immunosuppression and neutropenia)

Other treatments which may be needed are- Immunophoresis.

Steroid sparing immunosuppressants may be needed in severe cases after delivery.

Implications for the fetus- associated with intrauterine growth restriction- prudent to do monthly growth scans. Neonate may develop mild transient skin lesions due to passive antibody transfer ( 1 in 10).

Recurrence can occur in future pregnancies( may be earlier in onset and more severe) , with use of oral contraceptives ( which other Pregnancy-associated condition can recur with the use of combined oral contraceptives?* ) and with menstruation.

Consider doing a thyroid function test in Pemphigoid Gestationis patients ( due to its association with Grave’s disease)

Recommendations for use of Topical Steroids during Pregnancy- use the mildest form in the minimum dose to attain symptom control . Because there is a possible association between use of topical steroids and fetal growth restriction, the dose prescribed should preferably be less than 200 g during the entire pregnancy. Fetal growth should be monitored closely if the mother is on regular topical steroids.

To Summarize – Look for- Rash, Umbilical area, Bullae, Flexural areas, any itchy nodules.

1. Pruritus in pregnancy –> See if there is a rash. If No rash ( scratch marks should not be confused with rash), Or itching on palms and soles –> Investigate for Obstetric cholestasis or other systemic conditions.
2. If rash is present–> See if umbilicus is involved–>
3. Umbilicus is spared in Polymorphic Eruption of Pregnancy. ( other risk factors for polymorphic eruption are primi and excessive abdominal distension)
4. If umbilical area is involved, +_ bullae–> think of Pemphigoid Gestationis.
5. If ‘Atopic areas'( usually flexures) involved – Atopic eruption ( E type)

If severe itching with papular rashes –> think of Atopic Eruption ( P type)

6. Treatment- –> start with symptomatic treatment. Topical steroids to be used with caution. Seek dermatology review( skin biopsy may be needed)

5. Depending on the diagnosis, the fetus may need monitoring( E.g in Pemphigoid gestationis) .

Further reading

1. Maharajan A, Aye C, Ratnavel R, Burova E. Skin eruptions specific to pregnancy: an overview. The Obstetrician & Gynaecologist 2013; 15:233–40
2. BMJ 2014;348:g3489 doi: 10.1136/bmj.g3489 Skin disease in pregnancy Samantha Vaughan Jones,1 Christina Ambros-Rudolph,2 Catherine Nelson-Piercy

* Obstetric cholestasis.

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